SONY PICTURES ENTERTAINMENT INC. HEALTH AND WELFARE

Transcription

SONY PICTURES ENTERTAINMENT INC.
HEALTH AND WELFARE BENEFITS PLAN
Summary Plan Description
January 1, 2015
Our employees are the most valuable resource of Sony Pictures Entertainment Inc. (the
“Company”). To foster our commitment of excellence and strong community environment, we are
pleased to offer you a comprehensive, cost-effective, and competitive benefits package, which
includes health and welfare benefits. The Sony Pictures Entertainment Inc. Health and Welfare
Benefits Plan (the “Plan”) is designed to furnish you and your family with access to quality health
and welfare programs and provide protection against the hardship caused by catastrophic events.
This Summary Plan Description (“SPD”) outlines only the main provisions and features of the
Plan currently in effect and is comprised of this main document and the attachments, including the
attached Benefit Descriptions. You must read this main document and the attachments together to
understand your benefits, rights and obligations, keeping in mind that they are only summaries of
the Plan. This document and the attachments are not intended to give you any substantive rights to
benefits that are not provided under the official, legal Plan document. The legal plan document is
known as the Sony Pictures Entertainment Inc. Health and Welfare Benefits Plan. The Plan’s
terms cannot be modified by written or oral statements to you from human resources or benefits
personnel. In the event of any discrepancies between this SPD and the Plan, or between statements
made to you and the written Plan, the provisions of the Plan document, as amended from time to
time, will prevail.
Receipt of this SPD does not waive any eligibility requirement. This SPD is not a guarantee of
employment or benefits nor is it an employment contract. It supersedes any prior summary plan
description issued with respect to the Plan and any component benefits described herein. For
information regarding benefit eligibility for prior years, refer to the appropriate prior plan year
documents, copies of which are available from the Plan Administrator (contact information
below).
In this SPD, you will find:
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Information about eligibility for coverage, enrolling for coverage, when coverage begins
and when coverage ends.
A description of the benefits offered under the Plan.
Important administrative information about the Plan and your rights under the Employee
Retirement Income Security Act (“ERISA”).
The Plan includes component benefit programs that are subject to ERISA and programs that are
not subject to ERISA. Descriptions of component benefits that are not subject to ERISA are
included in this SPD for purposes of convenience and because there may be other applicable laws
(for example, the Internal Revenue Code) that require a written document. For example, the
premium conversion and dependent care FSA components of the Flex Benefits by Choice Plan and
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the Health Savings Account are not subject to ERISA, and their inclusion in this SPD is not
intended to subject those programs to the requirements of ERISA.
If you have any questions regarding any part of this SPD, contact the Plan Administrator at:
Sony Pictures Entertainment Inc.
10202 West Washington Boulevard
Sony Pictures Plaza, Suite 3900
Culver City, CA 90232-3119
310-244-4748
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TABLE OF CONTENTS
I.
ADMINISTRATION .............................................................................................. 4
II.
BENEFITS AND CONTRIBUTIONS ................................................................... 4
III.
ELIGIBILITY AND ENROLLMENT ................................................................... 5
IV.
TERMINATION OF COVERAGE ...................................................................... 16
V.
GENERAL ............................................................................................................ 17
VI.
LEAVES OF ABSENCE ...................................................................................... 20
VII.
LEGAL RIGHTS AND SELECTED STATUTORY PROVISIONS .................. 21
VIII.
STATEMENT OF ERISA RIGHTS ..................................................................... 28
IX.
GENERAL PLAN INFORMATION ................................................................... 30
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Participating Employers
Benefit Descriptions
Flex Benefits by Choice Plan Summary
Claims Procedures
Text of Mandated Prescription Drug Coverage and Medicare Notice and
Text of Mandated Premium Assistance Under Medicaid and the Children’s
Health Insurance Program (CHIP)
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ADMINISTRATION
The Company is the “Administrator” of the Plan and a “named fiduciary” within the meaning of
such terms as used in the Employee Retirement Income Security Act of 1974, as amended
(ERISA”). The Company is the Plan’s agent for service of legal process. The Company has the
duty and authority to interpret and construe the Plan in regard to all questions of eligibility, the
status and rights of any participant under the Plan, and the manner, time, and amount of payment of
any benefits under the Plan (if allowed under the applicable Insurance Policy). Further, the
Company, as the Plan Administrator, has the authority to interpret this SPD and the Plan
documents, and any such interpretation will be conclusive and binding on all persons unless the
Plan Administrator’s action is held to be arbitrary or capricious. Each employee shall, from time
to time, upon request of the Company, furnish to the Company such data and information as the
Company shall require in the performance of its duties under the Plan.
The Company may designate any person, entity or entities to carry out its duties and
responsibilities as Plan Administrator. The Company may adopt such rules and procedures as it
deems desirable for the administration of the Plan. Any term that begins herein with an initial
capital letter shall have the special meaning defined in the Plan, unless the context clearly requires
otherwise. References in this document to SPE, refers to the Company and each Participating
Employer (to the extent applicable; see Appendix A).
BENEFITS AND CONTRIBUTIONS
The Plan offers medical, prescription drug, dental, vision, life insurance, accidental death and
dismemberment, short-term disability, long-term disability, employee assistance benefits, health
care and dependent care flexible spending accounts, health savings accounts, severance pay, and
travel and accident insurance benefits. A summary of each benefit is set forth in Appendix B and
Appendix C, plan document, or other governing documents.
The cost of Plan benefits will be funded in part by SPE contributions and in part by pre-tax and/or
after-tax employee contributions. SPE will determine and periodically communicate your share of
the cost (if any) for benefits provided under each component program, and may change that
determination at any time.
SPE will make its contributions in an amount that (in our discretion) is at least sufficient to fund
the benefits or a portion of the benefits that are not otherwise funded by employee contributions.
SPE will pay its contribution and employee contributions to an insurer or HMO or, with respect to
benefits that are self-insured, will use these contributions to pay benefits directly to or on behalf of
employees or their eligible dependents from SPE's general assets. Employee contributions toward
the cost of a particular benefit will be used in their entirety prior to using SPE contributions to pay
for the cost of such benefit.
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ELIGIBILITY AND ENROLLMENT
Eligible Employees
You are eligible to participate in one or more Plan benefits set forth in the table below if you are:
 Employed and classified by a Participating Employer as an eligible employee who satisfies
the eligibility criteria set forth in the table for that benefit, and
 Not otherwise excluded from that benefit (as indicated), and
 Satisfy the eligibility criteria set forth in the underlying Benefit Description for the benefit.
To be considered an employee, the Participating Employer must treat you as its employee for
employment tax withholding purposes. Your employer has the sole and complete discretionary
authority to classify employees and other individuals performing services for it, and to determine
whether the eligibility requirements set forth herein have been satisfied. Individuals who are not
classified as members of an eligible category do not meet the eligibility requirements and are not
eligible for benefits under the Plan, even if your employer later determines that their classification
is erroneous, or should be retroactively revised. If a classification of an individual or group as
ineligible is determined to be incorrect or is revised retroactively, the individual nevertheless will
remain ineligible. This ineligible status will apply for all periods prior to the date your employer
or other authority concludes that the classification was incorrect and should be revised. A list of
Participating Employers is set forth in Appendix A.
Benefit
Eligibility Requirements
Specific Exclusions
PPO (includes medical,
prescription drugs)
Employees whose employment is with a
Participating Employer listed in Appendix A
who are not union employees and who are
classified by the Employer as either:
(i) a Regular, full-time Employee (regularly
scheduled to work at least 21 hours per week
over a five-day work week for an indefinite
period) working in the United States;
(ii) a Show Hire Employee;
(iii) Covered under a Term Deal, provided
that the Employer’s agreement with the
producer with respect to the Term Deal
expressly states the Employee is eligible to
participate in the Plan; or
(iv) a Term Deal II or SPA Term Deal
Employee
 Eligible to participate in another health and
Dental PPO (Group
Dental)
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welfare plan sponsored by the Employer
 Employed pursuant to a Term Deal (except as
otherwise specifically provided)
An intern
A trainee
A temporary employee
A consultant
A Production Hire
A Creative Services Production Hire
A Project Hire
Represented for collective bargaining with
respect to the terms and conditions of the
employee’s employment with the Employer
(except as otherwise specifically provided)
 A nonresident alien with no United States
source income
 An employee hired under a special program
such as a summer internship, a program for
students or the disadvantaged, or a
rehabilitation or training program
 An employee performing services in a
profession for which a guild has been
established, irrespective of whether the
employee is a member of such guild; eligible to
become a member of such guild; and/or eligible
to participate in the guild’s benefit plan(s), if
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any. This exclusion has some exceptions.
HDHP (includes,
medical, prescription
drugs) with HSA*
period) working in the United States;
(ii) a Show Hire Employee;
expressly states the Employee is eligible to
participate in the Plan; or
Employee; or
(v) a trainee
OR
A full-time Employee (regularly scheduled to
work 21 hours per week over a five-day work
week for an indefinite period) working in the
US, and classified by the Employer as:
(i) a Production Hire on an Imageworks
production working in the State of California
or New York who has received open
enrollment materials for a given Plan Year or
a personalized Certificate of Coverage and
employment with a “B2 Employer” ;
 Employed pursuant to a Term Deal (except as
An intern
A consultant
A Production Hire
A Project Hire
source income
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(ii) a Project Hire working in the State of
California or New York who has received
open enrollment materials for a given Plan
Year or a personalized Certificate of
Coverage and employment with a “B3
Employer”;
(ii) a Creative Services Production Hire or
working in the State of California or New
York who has received the open enrollment
materials for a given Plan Year or a
personalized Certificate of Coverage and
employment with a “B3 Employer” ; or
EPO (includes medical,
prescription drugs)
Dental DMO
Participating Employer listed in Appendix A,
period) working in the US;
(ii) a Show Hire Employee at “B1
Employer” ;
(iii) covered under a Term Deal (if agreement
with the producer expressly provides for
eligibility); or
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Eligible to participate in another health and
Employed pursuant to a Term Deal (except as
An intern
A consultant
A Production Hire (except as otherwise
specifically provided)
A Project Hire (except as otherwise
employee; or
(v) a trainee
.
OR
a personalized Certificate of Coverage, and
source income
rehabilitation or training program;
An employee performing services in a profession
for which a guild has been established,
irrespective of whether the employee is a
member of such guild; eligible to become a
member of such guild; and/or eligible to
participate in the guild’s benefit plan(s), if
Employer”;
(ii) a Creative Services Production Hire or
HMO (includes
medical, prescription
drugs)
Vision
Participating Employer listed in Appendix A,
period) working in the US;
(ii) a Show Hire Employee at “B1
Employer” ;
(iii) covered under a Term Deal (if agreement
with the producer expressly provides for
eligibility); or
employee; or
(v) a trainee
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.
OR
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a personalized Certificate of Coverage, and
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Employed pursuant to a Term Deal (except as
An intern
A consultant
A Production Hire (except as otherwise
A Project Hire (except as otherwise
A nonresident alien with no United States
source income
An employee hired under a special program
rehabilitation or training program;
An employee performing services in a
employee is a member of such guild; eligible
to become a member of such guild; and/or
eligible to participate in the guild’s benefit
plan(s), if any. This exclusion has some
exceptions.
Employer”;
(iii) a Creative Services Production Hire or
(iv) an Employee of the Employer represented
by Local 174 of the Office & Professional
Employees International Union (OPEIU) who
has not met the initial eligibility requirements
for the Motion Picture Industry Health Plan;
or
Flex Benefits (FSAs
premium pay, & HSA)
who are not union employees, and are
(i) Regular, full-time Employee (regularly
period) working in the United States; or
(ii) a Show Hire Employee
 Employed pursuant to a Term Deal, or Term
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Life Insurance, AD&D
who are not union employees, and who are
classified by the Employer as, either:
(i)
a Regular, full-time Employee
(regularly scheduled to work at least 21
hours per week over a five-day work
week for an indefinite period) working
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Deal II or SPA Term Deal
An intern
A trainee
A consultant or independent contractor (or their
employees)
A Production Hire
A Project Hire
respect to the terms and conditions of
employment with the Employer
A nonresident alien with no United States
source income.
An employee hired under a special program
rehabilitation or training program.
An employee performing services in a
An intern
A trainee
A consultant or independent contractor (or their
employees)
A Production Hire
 A Project Hire
 Represented for collective bargaining with
in the United States
(ii) a Show Hire Employee
expressly states that you are eligible to
participate in this Plan
(iv) A Term Deal II or SPA Term Deal
employee
Long Term Disability
Employees whose employment with a
Participating Employer listed in Appendix B,
who are not union employees, and who are
classified by the Employer as a Regular,
full-time Employee (regularly scheduled to
work at least 21 hours per week over a
five-day work week for an indefinite period)
working in the United States.
Employee Assistance
Plan
Employees who are eligible for a
Participating Employer sponsored medical
plan.
Business Travel
Accident
All full-time active employees, their spouse,
domestic partner and dependent children (up
to age 19 years or up to age 23 if a full-time
student), who are traveling on the business of
or at the expense of the Policyholder outside
their country of residence or permanent
assignment.
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source income.
any. This exclusion has some exceptions
 Employed pursuant to a Term Deal, or Term
Deal II or SPA Term Deal
 A Show Hire
 An intern
 A trainee
 A temporary employee
 A consultant or independent contractor (or their
employees)
 A Production Hire
 A Creative Services Production Hire
 A Project Hire
source income.
any. This exclusion has some exceptions
All applicable medical plan exclusions.
 A consultant or independent contractor (or their
employees)
 Persons for whom coverage is prohibited under
applicable law or who are not covered by
comprehensive medical insurance which
complies with legal and regulatory
requirements in their country of permanent
assignment will not be considered eligible for
this policy.
Benefit
Specific Exclusions
Severance Pay
Employees whose is with a participating
Employer listed in Appendix A who are not
union employees, and who are classified by
the Employer as a Regular, full-time at –will
employee (regularly scheduled to work at
least 21 hours per week over a five-day work
United States.; OR classified by the Employer
as a Show Hire and employed by “B1
Employer”
Employed pursuant to a Term Deal
 An intern
 A trainee
 A consultant
 A Show Hire (except as otherwise specifically
provided under the Severance Pay Policy with
respect to eligible employees of Sony Pictures
Imageworks Inc.)
 A Production Hire
 A Creative Services Production Hire
 A Project Hire

An employee whose conditions of
employment are determined by a
written contract
source income
 An employee regularly based outside of the
United States. This exclusion applies to all
employees who are entitled to severance pay
under the laws of any foreign jurisdiction, and
also to those employees regularly based abroad
who are not eligible under foreign severance
pay laws
An employee performing services in a profession
for which a guild has been established,
irrespective of whether the employee is a member
of such guild; eligible to become a member of
such guild; and/or eligible to participate in the
guild’s benefit plan(s), if any. This exclusion has
some exceptions.
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Benefit
Specific Exclusions
Expat Benefits
Employee in a Class of Eligible Employees
(defined below), who is an eligible, full-time
Employees, who normally work at least 21
hours a week.
A class of employee that is not a “Class of
Eligible Employees”.
Classes of Eligible Employees
The following Classes of Employees are
eligible for this insurance:
 All full-time Expatriates and Third Country
Nationals
 Employees working outside the United
States.
 All full-time Inpatriate Employees.
"Expatriate" means an Employee who is
working outside his country of citizenship.
"Inpatriate" means an Employee of the
Policyholder who is a citizen of another
country working in the United States.
"Third Country National" generally means an
Employee of the Policyholder who works
outside his country of citizenship, and outside
the Policyholder's country of domicile.
Persons for whom coverage is prohibited
under applicable law will not be considered
eligible under this component plan.
*
The HSA is not an SPE sponsored benefit. It’s an account owned by the employee. It is an employee’s
responsibility to make sure he/she is eligible to enroll in an HSA. For more information about the HSA, contact
Aetna/Payflex at 1-888-678-8242 or online at www.aetna.com or www.payflexdirect.com.
IMPORTANT: To be eligible for any Plan benefit, you, your Spouse, Domestic Partner and/or
Children must also satisfy the eligibility criteria set forth in the underlying Benefit Description for that
benefit. The Benefit Descriptions for each Plan benefit are attached to this Summary Plan Description
in Appendix B. In the event of any conflict between this Summary Plan Description and a Benefit
Description with respect to the eligibility requirements for a specific benefit, the underlying Benefit
Description will govern.
Eligibility for Spouses, Domestic Partners and Children
Some Plan benefits offer coverage for Spouses, Domestic Partners and/or Children. However, a
person cannot generally be covered under the Plan as your Spouse, Domestic Partner or Child if
they are also covered as an Eligible Employee.
Spouse
To be considered your “Spouse” under the Plan, the individual must be legally married to you
under state law.
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Domestic Partner
“A “Domestic Partner” for Plan purposes cannot be your Spouse. Rather, he/she is the individual
to whom you are registered with as domestic partners or to whom you have entered into a lawful
civil union within the state, if applicable, where he/she resides. If you do not satisfy this
requirement, you and the individual must meet and attest to each of the following for such
individual to be considered your Domestic Partner under the Plan:
 You are each other’s sole domestic partner and are emotionally committed to each other for
mutual care and support and intend to remain so indefinitely.
 You have resided together in the same principal residence for a full six months and intend to
remain so indefinitely.
 You are jointly responsible for each other’s financial welfare and basic living expenses (you
are financial interdependent).
 You are both at least 18 years of age and mentally competent to consent to a contract under the
laws of the state in which you reside.
 You are not related by blood closer than would bar marriage under applicable law in the state in
which you reside.
 You are not legally married to each other and are not legally married or separated from anyone
else.
Children
Children under age 26 are eligible for Plan benefits if:
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the child is born to you, your Spouse or Domestic Partner;
the child is placed with you, your Spouse or Domestic Partner for adoption (regardless of
whether the adoption is final);
a child acquired by you, your Spouse or Domestic Partner through legal guardianship (or, if
approved by the Plan Administrator in its sole and complete discretion, legal custody);
the child is your, your Spouse’s or Domestic Partner’s foster child legally placed by a licensed
agency; or
your stepchild.
In addition, a child meeting one of the previous requirements who is age 26 or older who became
permanently and totally disabled by age 26, as determined by the Plan Administrator, may be
eligible for Plan benefits.
Tax Consequences of Domestic Partner Coverage
If your enroll your Domestic Partner and/or your Domestic Partner’s Children under the Plan, your
federal tax consequences for such coverage will vary depending on whether such individuals
qualify as your “tax dependents” for purposes of receiving tax-free group health coverage. If such
individuals do qualify as your tax dependents, then any premiums paid by you for their coverage
may be deducted from your compensation on a pre-tax basis and your Participating Employer will
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not impute as income to you the value of any employer-provided coverage for such individuals. If
such individuals do not constitute your tax dependents, then any premiums paid by you for their
coverage will be deducted from your compensation on an after-tax basis and your Participating
Employer will impute as income to you the value of any employer provided coverage for such
individuals. The state tax consequences for same-sex Spouse or Domestic Partner coverage may
vary depending on your state of residence. Please contact your personal tax advisor for more
information.
IMPORTANT: To be eligible for any Plan benefit, you, your Spouse, Domestic Partner and/or
Children must also satisfy the eligibility criteria set forth in the underlying Benefit Description for that
benefit. The Benefit Descriptions for each Plan benefit are attached to this Summary Plan Description
in Appendix B. In the event of any conflict between this Summary Plan Description and a Benefit
Description with respect to the eligibility requirements for a specific benefit, the underlying Benefit
Description will govern.
Enrollment
New or Newly Eligible Employees
To become covered under the Plan or any of its components, you may enroll yourself (and, if
eligible your Spouse, Domestic Partner and/or Children) within 31 days of your hire date or, if
later, eligibility date to enroll for coverage. To facilitate efficient operation of the Plan, the Plan
may allow forms (including, for example, election forms and notices), whether required or
permissive, to be sent and/or made by electronic means.
If you do not affirmatively enroll or decline coverage within this election period and subject to any
different default rules as may be established by the Plan Administrator and described the initial
enrollment materials, you will be assigned the following employee-only coverage:
Benefit Plan*
Coverage Assigned**
Medical
HDHP
Dental
No Coverage
Vision
Employee Only
Employee Life and AD&D
Basic Life & AD&D
LTD
Basic LTD
Health Care FSA
No contribution
Dependent Care FSA
No contribution
Health Savings Account (HSA)
No contribution
Employee Assistance Plan
Coverage (employee)
Business Travel Accident Plan
Coverage
Severance Pay Plan
Coverage
*
Based on general plan eligibility requirements.
** In addition, automatic enrollment in certain coverage may preclude enrollment in certain options
during the next enrollment period.
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Coverage will be effective as of the first date of the month following your hire date or, if later,
eligibility date, after your enrollment materials are timely received in good order or you are
automatically enrolled in accordance with the above default rules, all in accordance with such rules
and procedures as may be established by the Plan Administrator. In addition, the effective date of
your coverage will be subject to such additional requirements as may be specified in the Benefit
Description for that benefit (e.g., coverage for life insurance may be conditioned upon evidence of
insurability, etc.).
Generally, elections you make are irrevocable and remain in effect for the remainder of the plan
year, unless you experience an eligible mid-year change (discussed below). You should keep
copies of any elections you make and carefully review any confirmations you receive from the
Plan (as well as your earnings statements). Contact the Plan Administrator immediately if you
notice any discrepancies or have any questions about Plan participation.
HSA Eligibility and Enrollment
An HSA is not an SPE sponsored plan. It is an individual trust or custodial account that you open
with an HSA trustee/custodian to be used primarily for reimbursement of eligible medical
expenses. It is your responsibility to make sure you are eligible to enroll in an HSA. You are
eligible to contribute to an HSA if you meet the requirements of § 223 of Internal Revenue Code,
participate in the high deductible health plan, and have not elected any disqualifying non-high
deductible health plan coverage.
To find out more about HSA eligibility requirements and the consequences of making
contributions to an HSA when you are not eligible (including possible excise taxes and other
penalties), see IRS Publication 969 (Health Savings Accounts and Other Tax-Favored Health
Plans) or contact Aetna/Payflex at 1-888-678-8242 or online at www.aetna.com or
www.payflexdirect.com. The HSA is discussed more in the Flex Benefits by Choice Plan’s
summary in Appendix C.
Open Enrollment
You may change your Plan benefit elections for you and your Spouse, Domestic Partner and
Children during any open enrollment period established by the Plan Administrator. Subject to any
different default rules as may be established by the Plan Administrator and described in the open
enrollment materials, if you do not affirmatively enroll or decline coverage during the open
enrollment, you will be deemed to have made the same election as was in effect for all benefits for
the preceding Plan Year to the extent permitted in the underlying Benefit Description, other than a
Health Care Flexible Spending Account, Dependent Care Flexible Spending Account, and/or any
available Health Savings Account (you will be deemed not have elected any such benefits).
Special Enrollment Rights/Health Insurance Portability and Accountability Act (HIPAA)
Loss of Other Coverage. If you decline enrollment for yourself or for an eligible dependent
(including your Spouse) while other health insurance or group health plan coverage is in effect and
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you stated on the election form that such other coverage was the reason you were declining
coverage, you may be able to enroll yourself and your dependents in the Plan if you or your
dependents lose eligibility for that other coverage (or if the employer stops contributing toward
your or your dependents’ other coverage). However, you must request enrollment within 31 days
after your or your dependents’ other coverage ends (or after the employer stops contributing
toward the other coverage).
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. In addition, if you have
a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and your new dependents in the Plan. However, you must request
enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
Gain or Loss of Coverage under Medicaid or State Child Health Plan. If you or your dependents
either gain eligibility for, or lose coverage under certain Medicaid or state child health plans, you
may be able to either cancel coverage under this Plan or enroll yourself and/or your dependents in
the Plan. You must submit an enrollment/waiver form within 60 days of the date such coverage is
terminated or you or your dependent become eligible for Medicaid or state health plan. For more
information, please see the notice attached to this SPD in Appendix F.
While not required by Federal law, the Plan also offers special enrollment rights to your Domestic
Partner and his or her Children that generally mirror the above rules. To request special
enrollment or obtain more information regarding your special enrollment rights, please contact the
Plan Administrator.
Other Mid-Year Changes
You are also permitted to change coverage for yourself and your Children, Spouse and/or
Domestic Partner who are treated as your tax dependents between annual open enrollment periods
for any of the permitted mid-year election change reasons set forth in the plan summary for the
Flex Benefits By Choice Plan set forth in Appendix C. You generally may change coverage for
your Domestic Partner and his or her Children who are not treated as your tax dependents using
mid-year election change rules that are similar to the rules set forth in the Flex Benefits By Choice
Plan. Mid-year changes to other benefits not offered under the Flex Benefits By Choice Plan may
be made as allowed by the Plan Administrator and underlying Benefit Descriptions.
Except as specified in any applicable Benefit Description, coverage changes typically will go into
effect as of the date of the underlying event provided the Plan is timely notified. After-tax
contributions and pre-tax contributions made under the Flex Benefits By Choice Plan will begin as
soon as practicable following the date you timely submit your forms in good order.
Rehired Employees
If your employment with a Participating Employer terminates and you are rehired during the same
plan year, please contact the Plan Administrator to determine the impact (if any) on your eligibility
and prior elections. See also the Flex Benefits by Choice Plan summary in Appendix C.
15
TERMINATION OF COVERAGE
Employee Coverage
Subject to any different rules that may be set forth in a Benefit Description for the underlying
benefit, your coverage under this Plan ends if:
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You cease to meet the Plan’s eligibility requirements,
You cease to be employed by any Participating Employer,
You experience a change in employment status (for example, switch from full to part time)
that makes you ineligible for Plan benefits,
You transfer to a non- Participating Employer,
You stop making required premium payments or other required contributions,
You die, or
The Plan is terminated or is amended to cause you to be ineligible.
Spouse and Domestic Partner Coverage
benefit, coverage for your Spouse or Domestic Partner under this Plan ends if:





You cease to be eligible,
You and your Spouse divorce or have your marriage annulled,
Your domestic partnership ends,
Your Spouse or Domestic Partner dies, or
The Plan is terminated or is amended to cause your Spouse or Domestic Partner to be
ineligible.
Child Coverage
benefit, coverage for your Children under this Plan ends if:






You cease to be eligible,
The Child turns 26 (unless disabled),
The Child is age 26 or older and ceases to be disabled,
Adoption proceedings for a Child placed for adoption are discontinued,
The Child dies, or
The Plan is terminated or is amended to cause your Child to be ineligible.
Date Coverage Ends
16
benefits, coverage ends on midnight of the last day of the month that includes an event described
above, except for life, accidental death and dismemberment, long-term disability, health care FSA
and dependent care FSA, which end as of midnight on the date of an event described above.
HSA Contributions
Contributions to an HSA made through the Flex Benefits By Choice Plan will cease when you are
no longer HSA eligible.
Continuation Coverage
Participants, Spouses, and Children who lose group health plan coverage may be able to elect
continued coverage under COBRA or state law (each discussed below). Domestic Partners are
eligible to elect continuation coverage similar to that provided under COBRA or state law.
GENERAL
Amendment and Termination
The Company intends to maintain the Plan indefinitely but is under no obligation to do so. The
Company can terminate the Plan at any time, for any or no reason, in its discretion.
Additional circumstances which may result in disqualification, ineligibility, denial, loss, forfeiture
or suspension of any benefits are described in the Benefit Descriptions that are attached to this
Summary Plan Description in Appendix B. Notwithstanding the foregoing, any retroactive
cancellation of group health coverage subject to the Patient Protection and Affordable Care Act
will comply with the Act’s limitation and requirements for rescission of coverage.
Claims Procedures
The Plan has formal procedures for claiming rights and benefits under the Plan and for resolving
disputes that may arise in connection with claims under the Plan by any person. Use of these
procedures is mandatory. The Claims Administrator with respect to each component benefit plan
is set forth in Section IX. General Plan Information.
The Plan’s claims procedures are attached to this Summary Plan Description in Appendix D and
are being furnished to you automatically, without charge, as a separate document. The Plan’s
insured benefits also have claims procedures set forth in the Benefit Descriptions. In the event of
any inconsistency between the procedures set forth in Appendix D and the procedures in an
applicable Benefit Description, the procedures in the Benefit Description shall control.
Generally, a claim must be filed as soon as possible after the date you have knowledge of the
existence of facts upon which your claim is based, but in no event later than 1 year following
that date unless the applicable Benefit Description provides otherwise. Until you have
17
exhausted your remedies under the Plan’s claims procedures you may not go to court to obtain
benefits and, unless a shorter period is contained in any applicable Benefit Description, any
such suit must be filed within 1 year after you exhaust your administrative remedies under
applicable claims procedures.
Coordination of Benefits
If you, your Spouse, Domestic Partner or Children become eligible for Plan benefits and are also
covered for the same benefits under another plan or policy, benefits under this Plan may be
coordinated with (i.e., reduced by) the benefits that are payable under the other plan or policy. The
Plan will coordinate with Medicare to the extent permitted by law. Please review the applicable
Benefit Descriptions for specific details regarding how the Plan coordinates benefits for that
benefit.
Subrogation
Except as otherwise set forth in the applicable Benefit Description, the Plan does not pay benefits
that are recoverable from other sources such as a judgment, legal settlement or payments made
through other insurance. The Plan may reduce benefits payable to you by the amount it expects
you, your Spouse, Domestic Partner and/or Children to recover from these other sources.
Alternatively, the Plan may pay you the benefits payable under the Plan without reduction from
these potential other sources with the understanding that if you actually do receive payment from
these other sources you will repay those amounts to the Plan. By accepting Plan benefits you, your
Spouse, Domestic Partner and/or Children agree to the Plan’s right of subrogation and you will
have assigned to the Plan the right to receive such amounts from the other sources. To the extent
you do receive such amounts, you will hold them in constructive trust for the benefit of the Plan
and the Plan will have an equitable lien on such amounts. The Plan’s right of recovery will not be
limited by any attorney’s fees you incur nor will it be reduced if you fail to recover all amounts you
are seeking. If you (or any of your agents) fail to cooperate with or otherwise hinder the Plan’s
efforts to recover such amounts, you and/or your dependents will cease to be entitled to any further
Plan benefits.
Overpayments
If the Plan pays you benefits by mistake, you agree to repay them to the Plan promptly after the
Plan requests repayment. If you do not repay any overpayment to the Plan promptly after the Plan
requests repayment, you will be assessed interest at the annual rate of 10 percent on such amounts
until you repay them to the Plan and will reimburse the Plan’s attorney’s fees in successfully
recovering such amounts. In addition to any other right of recovery the Plan may have for
overpayments, the Plan may recoup the overpayment from any future benefits payable to you, your
Spouse, Domestic Partner or Children.
Uncashed Checks
18
Except as otherwise set forth in an applicable Benefit Description, if a check is issued to you for
Plan benefits and you do not cash it within 180 days, such check will be automatically cancelled
and forfeited. Before the 180-day period has expired, you may request reissuance of any check
that was lost or misdelivered. After the expiration of the 180-day period, checks will only be
reissued if you file a timely request for Plan benefits in accordance with the Plan’s claims
procedures. Interest will not accrue on reissued checks. Amounts subject to forfeited checks will
be used to offset the reasonable costs of administering the Plan. Please keep the Plan
Administrator updated with your current address to minimize the likelihood of forfeited checks.
Insurance
Your right to recover Plan benefits funded solely through insurance policies shall be limited to the
amounts payable by such funding arrangements. Neither the Company nor any Participating
Employer has any independent obligation or duty to provide Plan benefits to the extent that such
benefits are to be provided by an insurance carrier, even if the carrier is unwilling or unable to
provide such benefits.
Fraud
No payments with respect to Plan benefits will be paid if you, your Spouse, Domestic Partner,
Children, or the provider of services for which payment is sought, attempts to perpetrate a fraud
upon the Plan or performs an act or omission that constitutes fraud, or if you, your dependent or the
provider of services makes an intentional misrepresentation of material fact with respect to any
claim. The Plan Administrator has the right to make the final determination of whether a fraud has
been attempted or committed upon the Plan or if a misrepresentation of fact has been made, and its
decision shall be final, conclusive and binding upon all persons. The Plan reserves the right, to the
fullest extent permitted by law, to cancel coverage, including retroactively, and fully recover any
amounts, with interest, improperly paid by the Plan by reason of fraud, attempted fraud, or
misrepresentation of fact and to pursue all other legal or equitable remedies. Any retroactive
cancellation of group health coverage pursuant to this section and subject to the Patient Protection
and Affordable Care Act will comply with the Act’s limitation and requirements for rescission of
coverage.
No Responsibility for Outcomes
The Plan does not provide health-related diagnoses, treatments, or services, although it pays for
them if its requirements are met, subject to the limitations it imposes. Neither the Company nor
any Participating Employer, any Plan fiduciary or any of its or their delegates, agents, or affiliates
guarantees any medical results or outcomes or is responsible for them, or makes any express or
implied warranties concerning the outcome of any covered services or supplies.
Plan Recoveries
If the Plan or SPE receives a rebate, refund, demutualization payment, excess surplus distribution
or any other recovery from an insurance carrier or other third party that constitutes “plan assets”
19
under ERISA in whole or in part, the Plan Administrator shall determine in its sole discretion the
portion of the payment that constitutes plan assets and how such portion, if any, should be utilized.
Notwithstanding the foregoing, if SPE is the policyholder or otherwise contracting with the third
party that is the source of recovery, then such recovery shall not constitute plan assets to the
maximum extent permitted by ERISA and other applicable law.
No Guarantee of Non-taxability
Neither the Company nor any Participating Employer, any Plan fiduciary or any of its or their
delegates, agents, or affiliates makes any commitment or guarantee that any amounts paid to you
or your dependents or for your benefit will not be taxable.
Foreign Language Statement
This Summary Plan Description contains a summary in English of your plan rights and benefits
under the Plan. If you have difficulty understanding any part of this document, contact the Plan
Administrator.
Rights May Not Be Assigned or Alienated
To the maximum extent permitted by law, the rights of any Participant, Spouse, Domestic Partner,
Child or dependent under the Plan may not be voluntarily or involuntarily assigned or alienated.
As a matter of convenience, the Plan may provide health benefits on behalf of such individuals by
paying their respective health care providers directly rather than requiring such individuals to first
pay the provider and then request reimbursement from the Plan. However, such providers shall
not be considered Plan participants or beneficiaries for any Plan purpose.
LEAVES OF ABSENCE
The Plan, in accordance with Company policy, complies with applicable Federal laws (discussed
below) that govern you and your dependents’ right to continue group health Plan benefits (e.g.,
medical, dental, vision, Health Care FSA) during an approved leave of absence. If you continue
coverage, it is your responsibility to pay the employee portion of the cost on the same schedule on
which they would have been made by salary reduction if you were not on leave of absence, or
another schedule of payments permitted by the Plan Administrator and applicable regulations.
Generally, contributions may be made on a pre-tax basis from taxable compensation due you, if
any, during the leave of absence, or paid on an after-tax basis if you go out on an unpaid leave. In
some cases, you may be able to pre-pay for your coverage or have catch-up contributions deducted
from your pay on a pre-tax basis when you return to employment. Employer contributions, if any,
will continue during the approved leave of absence.
If you take a non-FMLA leave or if you remain on leave after your FMLA is exhausted, your
benefits may continue at the discretion of the Plan Administrator. Further, non-health benefits
20
such as life insurance and Dependent Care FSA may be continued at the discretion of the Plan
Administrator and as allowed under the applicable Benefit Descriptions.
If you have any questions regarding the impact of a leave of absence on any of your Plan benefits,
please contact the Plan Administrator.
LEGAL RIGHTS AND SELECTED STATUTORY PROVISIONS
Family and Medical Leave Act of 1993
If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993
(“FMLA”), the Plan Administrator will continue to maintain your health care coverage on the
same terms and conditions as though you were still an active employee. That is, your employer
will continue to pay its share of the premiums to the extent you opt to continue coverage.
Generally, your participation will cease when the Company learns that you do not intend to return
to work after your leave or, if earlier, upon expiration of your FMLA leave if you fail to return to
work at such time. If your coverage ceases during your FMLA leave (for example, because you
opt not to continue coverage or due to nonpayment of your share of the premiums), you may be
able to resume your coverage upon your return. Under special rules that apply if an employee does
not return to work at the end of an FMLA leave, some individuals may be entitled to elect COBRA
continuation coverage. Please note that the Company retains the right to seek reimbursement from
you for contributions made on your behalf during the leave (for example, where the Company
makes any required employee contributions to ensure continuity of coverage). Please contact the
Plan Administrator if you have any questions regarding your rights under the FMLA.
Uniformed Services Employment and Reemployment Rights Act of 1994
Employees going into or returning from military service will have Plan rights mandated by the
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). These
rights include up to 24 months of extended health care coverage for the employee and any family
members covered under the Plan. Employees on military leave will maintain benefits as if he or
she were actively employed for the first 30 days of service. After 30 days, if an employee wishes
to retain group health coverage, he or she must pay for the entire cost of coverage plus a 2%
administration fee. Upon timely return from military leave, the employee shall be immediately
reinstated in coverage with no preexisting conditions exclusions applied in the Plan.
Coverage under other programs, such as life and disability, are governed by the Benefit
Descriptions found in Appendix B.
Only employees who are covered under the Plan immediately prior to leaving for military service
have rights mandated by USERRA. Please contact the Plan Administrator if you have questions
regarding your rights under USERRA.
COBRA Continuation of Coverage
21
If you are eligible to participate in, and do so participate in, one or more of the group health plan
benefits provided under the Plan, you may also have a right to COBRA continuation coverage,
which is a temporary extension of group health plan coverage. The right to COBRA continuation
coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of
1985 (“COBRA”). COBRA continuation coverage can become available to you and to other
members of your family who are covered under a group health plan when you would otherwise
lose your group health coverage. This section generally explains COBRA continuation coverage,
when it may become available to you and your family, and what you need to do to protect the right
to receive it. This section gives only a summary of your COBRA continuation coverage rights.
For more information about your rights and obligations under a particular group health plan and
under Federal law, you should either review the group health plan Benefits Descriptions attached
to this summary or which were already given to you, or contact the COBRA Administrator, who
administers COBRA continuation coverage for the Plan, at:
Conexis
PO Box 266101
Dallas, TX 75222-6101
1-877-722-2667
Except as stated in this section, or as may be offered at SPE’s sole discretion under Company
policy, the Plan does not provide group health plan coverage after your employment ends.
It’s important to note that when you and your covered dependents lose group health plan
coverage, other benefit options may be available to you and/or your eligible dependents. For
example, in addition to being eligible for COBRA continuation coverage, coverage under the
Health Insurance Marketplace (see www.HealthCare.gov or call 1-800-318-2596) or coverage
under another employer’s plan may be available to you and/or your eligible dependents at lower
rates. You should compare any other coverage options available with COBRA continuation
coverage and choose the coverage that is best for you.
Overview
COBRA continuation coverage is a continuation of group health plan coverage when coverage
would otherwise end because of a life event known as a “qualifying event.” Specific qualifying
events are listed later in this section. COBRA continuation coverage must be offered to each
person who is a “qualified beneficiary.” A qualified beneficiary is someone who will lose
coverage under a group health plan because of a qualifying event. Depending on the type of
qualifying event, employees, Spouses of employees, and dependent Children of employees may be
qualified beneficiaries. Under the group health plan, qualified beneficiaries who elect COBRA
continuation coverage must pay for COBRA continuation coverage.
Note that while COBRA continuation coverage does not, under Federal law, extend to domestic
partners, the Plan Administrator, in its sole discretion, extends continuation coverage to Domestic
Partners under rules similar to the COBRA rules described herein. Contact the Plan Administrator
should you have any questions concerning the availability of continuation coverage for your
Domestic Partner.
22
Qualifying Event
If you are an employee, you will become a qualified beneficiary if you will lose your group health
plan coverage under the Plan because either one of the following qualifying events happens:


Your hours of employment are reduced, or
Your employment ends for any reason other than your gross misconduct.
If you are the Spouse of an employee, you will become a qualified beneficiary if you will lose your
group health plan coverage under the Plan because any of the following qualifying events happens:





Your spouse dies,
Your spouse’s hours of employment are reduced,
Your spouse’s employment ends for any reason other than his or her gross misconduct,
Your spouse becomes enrolled in Medicare (Part A, Part B, or both), or
You become divorced or legally separated from your spouse.
If an employee cancels coverage for his or her Spouse in anticipation of a divorce or legal
separation, and a divorce or legal separation later occurs, then the divorce or legal separation may
be considered a qualifying event even though the ex-spouse lost coverage before the divorce or
separation.
Your dependent Children will become qualified beneficiaries if they will lose group health plan
coverage under the Plan because any of the following qualifying events happens:






The parent-employee dies,
The parent-employee’s hours of employment are reduced,
The parent-employee’s employment ends for any reason other than his or her gross
misconduct,
The parent-employee becomes enrolled in Medicare (Part A, Part B, or both),
The parents become divorced or legally separated, or
The child stops being eligible for coverage under the Group Plan as a “dependent child.”
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the
COBRA Administrator has been timely notified that a qualifying event has occurred. When the
qualifying event is the end of employment or reduction of hours of employment, death of the
employee, or enrollment of the employee in Medicare (Part A, Part B, or both), the COBRA
Administrator will take notice of the qualifying event within 30 days following the date coverage
ends.
IMPORTANT: For the other qualifying events (divorce or legal separation of the employee and
Spouse or a dependent Child’s losing eligibility for coverage as a dependent child), you or your
Spouse or dependent must notify the COBRA Administrator. The Plan requires you to notify the
COBRA Administrator in writing within 60 days after the date your coverage ends by mailing
written notice to:
23
Conexis
PO Box 226101
Dallas, TX 75222-6101
1-877-722-2667
Your notice must be postmarked no later than the last day of the required notice period. Any
notice you provide must state the name of the health plan under which you received coverage, the
name and address of the employee covered under the plan, and the name(s) and address(es) of the
qualified beneficiary(ies). Your notice must also name the qualifying event and the date it
happened. If the qualifying event is a divorce, your notice must include a copy of the divorce
decree.
If you or your Spouse or dependents do not provide written notice to the COBRA Administrator
during the 60-day notice period, any individual who loses coverage will NOT BE OFFERED
THE OPTION TO ELECT COBRA CONTINUATION COVERAGE.
Once the COBRA Administrator receives timely notice that a qualifying event has occurred,
COBRA continuation coverage will be offered to each of the qualified beneficiaries. For each
qualified beneficiary who timely elects COBRA continuation coverage, COBRA continuation
coverage will begin on the date that the group health plan coverage under the Plan would otherwise
have been lost. If you or your Spouse or your dependent Children do not elect continuation
coverage within the 60-day election period, YOU WILL LOSE YOUR RIGHT TO ELECT
CONTINUATION COVERAGE.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying
event is the death of the employee, enrollment of the employee in Medicare (Part A, Part B, or
both), your divorce or legal separation, or a dependent Child losing eligibility as a dependent child,
COBRA continuation coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the employee’s hours of
employment, COBRA continuation coverage lasts for up to 18 months. There are two ways in
which this 18-month period of COBRA continuation coverage can be extended.
Disability Extension of 18-Month Period of Continuation Coverage
If you or anyone in your family receiving group health plan coverage under the Plan is determined
by the Social Security Administration to be disabled at any time during the first 60 days of
COBRA continuation coverage and you notify the COBRA Administrator in a timely fashion, you
and all family members who had coverage (all qualified beneficiaries) can receive up to an
additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. You
must make sure that the COBRA Administrator is notified of the Social Security
Administration’s determination within 60 days of the date of the determination and before
the end of the 18-month period of COBRA continuation coverage. This written notice should
be sent to the COBRA Administrator at the same address shown above, and must include the name
of the disabled qualified beneficiary, the date that the qualified beneficiary became disabled, and
24
the date the Social Security Administration made its determination. Your notice should also
include a copy of the Social Security Administration’s determination. IF THESE
PROCEDURES ARE NOT FOLLOWED OR IF THE NOTICE IS NOT PROVIDED IN
WRITING TO THE COBRA ADMINISTRATOR WITHIN THE REQUIRED PERIOD,
THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA CONTINUATION
COVERAGE.
Second Qualifying Event Extension of 18-Month Period of Continuation Coverage
If your family experiences another qualifying event while receiving COBRA continuation
coverage (e.g., by reason of your termination of employment or reduction in hours), the Spouse
and dependent Children in your family can get additional months of COBRA continuation
coverage, up to a maximum of 36 months. This extension is available to the Spouse and dependent
Children if the former employee dies, enrolls in Medicare (Part A, Part B, or both), or gets
divorced or legally separated. If the second qualifying event is a divorce, your notice must include
a copy of the divorce decree. The extension is also available to a dependent Child when that child
stops being eligible under the group health plan as a dependent child. In all of these cases, you
must make sure that the COBRA Administrator is notified of the second qualifying event within
60 days of the second qualifying event. This written notice must be sent to the COBRA
Administrator at the same address shown above. IF THE NOTICE IS NOT PROVIDED IN
WRITING TO THE COBRA ADMINISTRATOR WITHIN THE REQUIRED 60-DAY
PERIOD, THEN THERE WILL BE NO EXTENSION OF COBRA CONTINUATION
COVERAGE DUE TO A SECOND QUALIFYING EVENT.
Medicare Extension for Spouse and Dependent Children
If a qualifying event that is a termination of employment or reduction of hours occurs within 18
months after the covered employee becomes entitled to Medicare, then the maximum coverage
period for the Spouse and dependent Children will end three years from the date the employee
became entitled to Medicare (but the covered employee’s maximum coverage period will be 18
months). The maximum COBRA coverage period for Spouses and/or dependents will be 36
months.
Shorter Maximum Coverage Period For Health FSAs
The maximum COBRA coverage period for a health flexible spending arrangement (health FSA)
maintained by the employer normally ends on the last day of the Plan year in which the qualifying
event occurred. Refer to the Flex Benefits By Choice Plan’s summary in Appendix C for more
details.
Children Born to or Placed For Adoption With Covered Employee During COBRA Period
A Child born to, adopted by or placed for adoption with a covered employee during a period of
continuation coverage is considered to be a qualified beneficiary provided that, if the covered
employee is a qualified beneficiary, the covered employee has elected continuation coverage for
himself or herself. The Child’s COBRA coverage begins when the Child is enrolled in the Plan,
25
whether through special enrollment or open enrollment, and it lasts for as long as COBRA
coverage lasts for other family members of the employee. To be enrolled in the Plan, the Child
must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age).
Alternate Recipients Under QMCSOs
A child of the covered employee who is receiving benefits under the Plan pursuant to a Qualified
Medical Child Support Order (QMCSO) received by the Plan Administrator during the covered
employee’s period of employment with the employer is entitled to the same rights under COBRA
as a dependent Child of the covered employee, regardless of whether that child would otherwise be
considered a dependent.
Questions About COBRA Continuation Coverage
If you have questions about your COBRA continuation coverage, you should contact the COBRA
Administrator at the phone number or address shown above, or you may contact the nearest
Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (“EBSA”). Addresses and phone numbers of Regional and District EBSA Offices
are available through EBSA’s website at www.dol.gov/ebsa.
California COBRA
In some situations, you may be entitled to a further period of continuation coverage under
California’s own COBRA-type law (“California COBRA”). California COBRA may extend the
period for continuation coverage to a maximum of 36 months from the date of the initial qualifying
event. California COBRA is effective only after your other COBRA coverage is exhausted.
California COBRA coverage is more expensive than regular COBRA coverage, and is only
available under a California-based HMO. Details are available by contacting the insurance carrier.
Keep the COBRA Administrator Informed of Address Changes
In order to protect your family’s rights, you should keep the COBRA Administrator informed of
any changes in the addresses of family members. You should also keep a copy, for your records,
of any notices you send to the COBRA Administrator.
HIPAA Privacy Rights
Under HIPAA, group health plans are required to take steps to ensure that certain “protected health
information” (PHI) is kept confidential. You may receive a separate Notice of Privacy Practices
from the Company (or medical insurers) that outlines the plan’s health privacy policies, including
with regard to electronic PHI. If you have a complaint, questions, concerns or need a copy of the
Notice of Privacy Practices, you may contact:
Privacy Officer
Attention: Gabrielle Ernst
10202 West Washington Boulevard, SPP 3854
26
Culver City, CA 90232
Qualified Medical Child Support Orders
This Plan will also provide benefits as required by any qualified medical child support order
(QMCSO), as defined in ERISA §609(a), and provide benefits, pursuant to a QMCSO, to
dependent children placed with participants or beneficiaries for adoption under the same terms and
conditions as apply in the case of dependent children who are natural children of participants or
beneficiaries, in accordance with ERISA §609(c). The Plan maintains detailed administrative
procedures for addressing qualified medical child support orders. You can obtain these, without
charge, by contacting the Plan Administrator.
Newborns’ and Mothers’ Health Protection Act of 1996
Group health plans and health insurance issuers generally may not, under Federal law, restrict
benefits for any hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean
section. However, Federal law generally does not prohibit the mother’s or newborn’s attending
provider, after consulting with the mother, from discharging the mother or her newborn earlier
than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal
law, require that a provider obtain authorization from the plan or the issuer for prescribing a length
of stay not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act of 1998
This Plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides the
following mastectomy-related services:




Reconstruction of the breast on which mastectomy has been performed;
Surgery and reconstruction on the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment for physical complications of all stages of mastectomy, including
lymphademas.
These benefits will be provided subject to the same deductibles and coinsurance applicable to
other medical and surgical benefits provided under the Plan. For more information, please contact
the Plan Administrator.
The Patient Protection and Affordable Care Act - Patient Protections
The HMO Plan generally allows the designation of a primary care provider. You have the right to
designate any primary care provider who participates in our network and who is available to accept
you or your family members. For information on how to select a primary care provider, and for a
list of the participating primary care providers, contact the Plan Administrator.
27
For children, you may designate a pediatrician as the primary care provider.
You do not need prior authorization from the HMO Plan or from any other person (including a
primary care provider) in order to obtain access to obstetrical or gynecological care from a health
care professional in our network who specializes in obstetrics or gynecology. The health care
professional, however, may be required to comply with certain procedures, including obtaining
prior authorization for certain services, following a pre-approved treatment plan, or procedures for
making referrals. For a list of participating health care professionals who specialize in obstetrics
or gynecology, contact the Plan Administrator.
Medicare Part D – Notice of Credible Coverage
Medicare Part D is prescription drug coverage offered to eligible individuals. SPE is required to
send a Notice of Credible Coverage to Medicare Part D eligible individuals pursuant to Title XVIII
of the Social Security Act. The Notice is intended to assist Part D eligible individuals in making
informed and timely decision of whether to enroll in Part D coverage and help such individuals
avoid paying higher premiums for Part D coverage. A copy of this notice can be found in
Appendix E.
Premium Assistance Under Medicaid and the Children’s Health Insurance
Program (CHIP)
Employers, like SPE, that maintain a group health plan in a State that provides premium assistance
under Medicaid or Children’s Health Insurance Program must notify all employees of potential
opportunities for premium assistance in the State in which the employee resides. A copy of the
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) notice
can be found in Appendix F.
Non-discrimination
The Plan may not discriminate against any individual or dependent of that individual with respect
to health coverage on the basis of a health factor. Further, the Plan will not adjust premium
contribution amounts based on genetic information, request or require an individual or family
member of an individual to undergo a genetic test (except in certain circumstances related to
research), or request, require, or purchase genetic information with respect to any individual prior
to the individual’s enrollment in the Plan or coverage in connection with enrollment in the Plan.
STATEMENT OF ERISA RIGHTS
Note that certain benefits described in this SPD are not subject to ERISA (e.g., the premium
conversion and dependent care FSA components of the Flex Benefits by Choice Plan and the
Health Savings Account) and the following Statement of ERISA Rights does not apply to these
programs.
28
As a participant in the Plan, which is described in this summary plan description, you are entitled
to certain rights and protections under the Employee Retirement Income Security Act of 1974
(“ERISA”). ERISA provides that all plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator's office and at other specified locations, such
as worksites and union halls, all documents governing the plan, including insurance contracts and
collective bargaining agreements, and a copy of the latest annual report (Form 5500 series) filed by
the plan with the U.S. Department of Labor and available at the Employee Benefits Security
Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the
operation of the plan, including insurance contracts and collective bargaining agreements, and
copies of the latest annual report (Form 5500 Series) and updated summary plan description. The
Plan Administrator may make a reasonable charge for the copies.
Receive a summary of the Plan's annual financial report. The Plan Administrator is required by
law to furnish each participant with a copy of this summary annual report.
Continue Group Health Coverage
Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage
under the Plan as a result of a qualifying event. You or your dependents may have to pay for such
coverage. Review this summary plan description and the documents governing the Plan on the
rules governing your COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under
your group health plan, if you have creditable coverage from another plan. You should be
provided a certificate of creditable coverage, free of charge, from your group health plan or health
insurance issuer when you lose coverage under the plan, when you become entitled to elect
COBRA continuation coverage, and when your COBRA continuation coverage ceases, if you
request it before losing coverage, or if you request it up to 24 months after losing coverage.
Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion
for 12 months (18 months for late enrollees) after your enrollment date in your coverage. Note that
certificates of creditable coverage are no longer required beginning December 31, 2014, because
plans are not permitted to impose preexisting condition exclusions for any plan year beginning on
or after January 1, 2014.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan,
called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other
plan participants and beneficiaries. No one, including your employer, your union, or any other
29
person, may fire you or discriminate against you in any way to prevent you from obtaining a
welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request
a copy of plan documents or the latest annual report from the plan and do not receive them within
30 days, you may file suit in a Federal court. In such a case, the court may require the Plan
Administrator to provide the materials and pay you up to $110 a day until you receive the materials,
unless the materials were not sent because of reasons beyond the control of the administrator. If
you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a
state or Federal court once you have exhausted the Plan’s claims and appeals procedures;
provided, however, that you do so within one year after exhausting those claims and appeals
procedures (or such other shorter period as may be provided in claims procedures
established by the applicable Claims Administrator). In addition, if you disagree with the
plan’s decision or lack thereof concerning the qualified states of a domestic relations order or a
medical child support order, you may file suit in Federal court. If it should happen that plan
fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights,
you may seek assistance from the U. S. Department of Labor, or you may file suit in a Federal
court. The court will decide who should pay court costs and legal fees. If you are successful, the
court may order the person you have sued to pay these costs and fees. If you lose, the court may
order you to pay these costs and fees, for example, if it finds your claim is frivolous.
If you have any questions about the Plan, you should contact the Plan Administrator. If you have
any questions about this statement or about your rights under ERISA, or if you need assistance in
obtaining documents from the Plan Administrator, you should contact the nearest office of the
Employee Benefits Security Administration, U. S. Department of Labor, listed in your telephone
directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U. S. Department of Labor, 200 Constitution Avenue, N. W., Washington D. C.
20210. You may also obtain certain publications about your rights and responsibilities under
ERISA by calling the publications hotline of the Employee Benefits Security Administration.
GENERAL PLAN INFORMATION
Plan Name(s):
Sony Pictures Entertainment Inc. Health and Welfare Benefits Plan
Plan Number:
501
Plan Year:
Calendar year
Plan Sponsor and
30
Plan Administrator:
Plan’s Sponsor’s EIN:
13-3265777
Source of Contributions:
Contributions to the Plan are made by Participating Employers
and/or Plan participants.
Benefits Offered:
The Plan offers the following welfare benefits for eligible
employees and their eligible spouses, domestic partners and/or
children: medical, prescription drug, dental, vision, life insurance,
accidental death and dismemberment, short-term disability,
long-term disability, employee assistance benefits, health care and
dependent care flexible spending accounts, health savings accounts,
severance pay, and business travel and accident insurance.
Type of Benefit
Medical, , Prescription Drugs (PPO)
Insurance Carrier and/or
Claims Administrator
Aetna
151 Farmington Avenue
Hartford, CT 06156
1-888-385-1053
www.aetna.com
ASA #810072
Express Scripts
8111 Royal Ridge Parkway
Irving, TX 75063
1-800-716-2773
www.express-scripts.com
Group #SONYRX
Medical, , Prescription Drugs (HMO)
Kaiser (CA only)
Member Service Call Center:
toll free 1-800-464-4000 (TTY
users call 1-800-777-1370)
weekdays 7 a.m.–7 p.m.,
weekends 7 a.m.–3 p.m.
(except holidays)
kp.org
Medical, Prescription Drugs (HDHP with
HSA)
Aetna
Hartford, CT 06156
1-888-385-1053
www.aetna.com
ASA #810072
Express Scripts
Irving, TX 75063
31
1-800-716-2773
Group #SONYRX
Medical, Prescription Drugs (EPO)
Aetna
Hartford, CT 06156
1-888-385-1053
www.aetna.com
ASA #810072
Express Scripts
Irving, TX 75063
1-800-716-2773
Group #SONYRX
Vision
Vision Service Plan (“VSP”)
3333 Quality Drive
Rancho Cordova, CA 95670
1-800-877-7195
www.vsp.com
Group #00111374
Dental (PPO)
Aetna Life Insurance
Company
Hartford, CT 06156
1-888-385-1053
www.aetna.com
ASA #810072
Dental (DMO)
Aetna Dental of California Inc.
6303 Owensmouth Ave.
Woodland Hills, CA 91367
1-877-238-6200
www.aetna.com
ASA #810072
Life Insurance
Life Insurance Company of
North America
1601 Chestnut Street
Philadelphia, PA 19192-2235
1-800-732-1603
FLX-980248
Accidental Death and Dismemberment
Insurance
North America
32
1-800-732-1603
OK 980268
Long-Term Disability Insurance
After 10/1/14:
Liberty Mutual
PO Box 7209
London, KY 40742-7209
1-800-320-7585
Mylibertyconnection.com
Prior to 10/1/14: Life
Insurance Company of North
America
1-800-732-1603
FLK-980103
Employee Assistance Plan
Business Travel and Accident Insurance
Flexible Spending Accounts (health and
dependent care) and Health Savings Account
Expat Medical and Dental
Expat Life, AD&D and Disability
Severance Pay Plan
33
ComPsych Guidance
Resources
1-855-327-7669
www.guidance resources.com
(web ID: EAPSONY)
North America
ABL 961896
Aetna/Payflex
Hartford, CT 06156
1-888-385-1053
www.aetna.com
ASA #810072
Aetna International
PO Box 981543
EL Paso, TX 79998-1543
1-800-231-7729 (via AT&T
access code; collect outside
US)
1-813-775-0190 (direct)
www.aetnainternational.com
Control #840320
Zurich American Life
Insurance Company
1400 American Lane
Schaumburg, Illinois 60196
Policy 2010-1TR
SPE
10202 W. Washington Blvd,
SPP 3900
1-310-244-4748
Agent for Service of
Legal Process:
10202 West Washington Boulevard
Sony Pictures Plaza, Suite 3900
Culver City, CA 90232-3119
34
APPENDIX A
PARTICIPATING EMPLOYERS
Component Benefits
PPO and HDHP with
HSA (includes medical,
prescription drugs);
Vision, Dental PPO
(Group Dental)
Braddock Production Services, Inc., Colton Productions, Inc., Columbia Pictures Industries, Inc.,
Columbia TriStar Marketing Group, Inc., Columbia TriStar Television, Inc., CPE Holdings, Inc.,
CPE US Networks Inc., CPE US Networks II Inc., CPE US Networks III Inc., CPT Holdings, Inc.,
Crackle, Inc., Crackle Latin America, Inc., Culver Digital Distributions, Inc., , Embassy Row, LLC,
Quadra Productions, Inc., Screen Gems, Inc., SET Distribution, LLC, Sony Movie Channel, Sony
Pictures Animation Inc., Sony Pictures Classics Inc., Sony Pictures Digital Inc., Sony Pictures
Entertainment Inc., Sony Pictures Home Entertainment Inc., Sony Pictures Imageworks Inc., Sony
Pictures Post Production Services Inc., Sony Pictures Releasing Corporation, Sony Pictures Releasing
International Corporation, Sony Pictures Studios Inc., Sony Pictures Television Inc., Sony Pictures
Television Advertising Sales Company, Sony Pictures Television Networks Games Inc., Sony
Pictures Worldwide Acquisitions Inc., SPE Corporate Services Inc., SPE-WPF Inc., TriStar Pictures,
Inc., TriStar Television, Inc.
HMO and EPO
(includes medical,
vision, prescription
drugs); Vision, DMO
“B Employers”: Braddock Production Services, Inc., Colton Productions, Inc., Columbia Pictures
Industries, Inc., Columbia TriStar Marketing Group, Inc., Columbia TriStar Television, Inc., CPE
Holdings, Inc., CPE US Networks Inc., CPE US Networks II Inc., CPE US Networks III Inc., CPT
Holdings, Inc., Crackle, Inc., Crackle Latin America, Inc., Culver Digital Distributions, Inc., ,
Embassy Row, LLC, Quadra Productions, Inc., Screen Gems, Inc., SET Distribution, LLC, Sony
Movie Channel, Sony Pictures Animation Inc., Sony Pictures Classics Inc., Sony Pictures Digital
Inc., Sony Pictures Entertainment Inc., Sony Pictures Home Entertainment Inc., Sony Pictures
Imageworks Inc., Sony Pictures Post Production Services Inc., Sony Pictures Releasing Corporation,
Sony Pictures Releasing International Corporation, Sony Pictures Studios Inc., Sony Pictures
Television Inc., Sony Pictures Television Advertising Sales Company, Sony Pictures Television
Networks Games Inc., Sony Pictures Worldwide Acquisitions Inc., SPE Corporate Services Inc.,
SPE-WPF Inc., TriStar Pictures, Inc., TriStar Television, Inc.
“B1 Employers”: Screen Gems, Inc., Sony Pictures Animation Inc., Sony Pictures Imageworks Inc.
“B2 Employer”: Sony Pictures Imageworks Inc.
“B3 Employers”: CPE US Networks, Inc., Crackle, Inc., Sony Pictures Entertainment Inc.
Flex Benefits (FSAs &
premium pay; HSA)
Life Insurance, AD&D
35
Inc., TriStar Television, Inc..
LTD
EAP
Same as medical plans
BTA
As determined by Employer in its discretion
Component Benefits
Severance
“B Employers”: Braddock Production Services, Inc., Colton Productions, Inc., Columbia Pictures
Industries, Inc., Columbia TriStar Marketing Group, Inc., Columbia TriStar Television, Inc., CPE
Holdings, Inc., CPE US Networks Inc., CPE US Networks II Inc., CPE US Networks III Inc., CPT
Holdings, Inc., Crackle, Inc., Crackle Latin America, Inc., Culver Digital Distributions, Inc., ,
Embassy Row, LLC, Quadra Productions, Inc., Screen Gems, Inc., SET Distribution, LLC, Sony
Movie Channel, Sony Pictures Animation Inc., Sony Pictures Classics Inc., Sony Pictures Digital
Inc., Sony Pictures Entertainment Inc., Sony Pictures Home Entertainment Inc., Sony Pictures
Imageworks Inc., Sony Pictures Post Production Services Inc., Sony Pictures Releasing Corporation,
Sony Pictures Releasing International Corporation, Sony Pictures Studios Inc., Sony Pictures
Television Inc., Sony Pictures Television Advertising Sales Company, Sony Pictures Television
Networks Games Inc., Sony Pictures Worldwide Acquisitions Inc., SPE Corporate Services Inc.,
SPE-WPF Inc., TriStar Pictures, Inc., TriStar Television, Inc.
“B1 Employer”: Sony Pictures Imageworks Inc.
Expat Benefits
As determined by Employer in its discretion
36
APPENDIX B
BENEFIT DESCRIPTIONS
B.1
MEDICAL - AETNA PLANS
B.2
MEDICAL - KAISER HMO
B.3
PRESCRIPTIONS
B.4
VISION
B.5
DENTAL - PPO (GROUP DENTAL)
B.6
DENTAL - DMO
B.7
LIFE AND ACIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE
B.8
BUSINESS TRAVEL ACCIDENT (BTA) INSURANCE
B.9
LONG TERM DISABILITY (LTD)
B.10
EMPLOYEE ASSISTANCE PROGRAM
B.11
EXPAT BENEFITS
B.12
SEVERANCE PAY & BENEFITS
37
B.1 MEDICAL AETNA PLANS
AETNA CONSUMER CHOICE PLAN
Schedule of Benefits
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Individual Deductible*
$1,300
$2,600
Family Deductible*
$2,600
$5,200
Calendar Year Deductible*
*Unless otherwise indicated, any applicable deductible must be met before benefits are paid.
Plan Maximum Out of Pocket Limit includes plan deductible.
Plan Maximum Out of Pocket Limit excludes precertification penalties.
Individual Maximum Out of Pocket Limit:


For network expenses: $3,750.
For out-of-network expenses: $7,500.
Family Maximum Out of Pocket Limit:


Lifetime Maximum Benefit per
person
Unlimited
Unlimited
Payment Percentage listed in the Schedule below reflects the Plan Payment Percentage. This is the amount the
Plan pays. You are responsible to pay any deductibles and the remaining payment percentage. You are
responsible for full payment of any non-covered expenses you incur.
All Covered Expenses Are Subject To The Calendar Year Deductible Unless Otherwise Noted In The Schedule
Below.
Maximums for specific covered expenses, including visit, day and dollar maximums are combined maximums
between network and out-of-network, unless specifically stated otherwise.
PLAN FEATURES
Preventive Care Benefits
Routine Physical Exams
Office Visits
NETWORK
OUT-OF-NETWORK
100% per visit
80% per visit after Calendar Year
38
deductible
No copay or deductible applies.
Covered Persons through age 21: Subject to any age and visit limits
Maximum Age & Visit Limits
provided for in the comprehensive
guidelines supported by the Health
Resources and Services
Administration.
Subject to any age and visit limits
Administration.
Covered Persons ages 22 but less 1 visit
than 65:
Maximum Visits per Calendar
Year
1 visit
Covered Persons age 65 and
over:
Year
1 visit
1 visit
100% per visit
deductible
Preventive Care Immunizations
Performed in a facility or
physician's office
Screening & Counseling Services - 100% per visits
Obesity, Misuse of Alcohol and/or
Drugs & Use of Tobacco Products No copay or deductible applies.
Obesity
Maximum Visits per Calendar Year 26 visits (however, of these only 10
(This maximum applies only to
visits will be allowed under the
Covered Persons ages 22 & older.) Plan for healthy diet counseling
provided in connection with
Hyperlipidemia (high cholesterol)
and other known risk factors for
cardiovascular and diet-related
chronic disease)*
80% per visits after Calendar Year
deductible
26 visits (however, of these only 10
Plan for healthy diet counseling
chronic disease)*
*Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit.
39
Misuse of Alcohol and/or Drugs
Year
5 visits*
5 visits*
Use of Tobacco Products
Maximum Visits per Calendar Year 8 visits*
8 visits*
Well Woman Preventive Visits
Office Visits
100% per visit
deductible
No Calendar Year deductible
applies.
Maximum Visits per Calendar Year 1 visit
1 visit
Hearing Exam
deductible
60% per exam after Calendar Year
deductible
Maximum exams per 12 month
period
1 exam
1 exam
Hearing Supply Maximum per 36
month period
1 hearing aid per ear
PLAN FEATURES
Routine Cancer Screenings
NETWORK
OUT-OF-NETWORK
Outpatient
100% per visit
deductible
applies.
40
Maximums
Prenatal Care
Office Visits
provided for in the current
recommendations of the United
States Preventive Services Task
Force and comprehensive
Administration.
Administration.
For details, contact your physician,
log onto the Aetna website
www.aetna.com, or call the number
on the back of your ID card.
100% per visit
deductible.
Important Note: Refer to the Physician Services and Pregnancy Expenses sections of the Schedule of Benefits
for more information on coverage levels for pregnancy expenses under this Plan, including other prenatal care,
delivery and postnatal care office visits.
Comprehensive Lactation Support and Counseling Services
100% per visit
Lactation Counseling Services
Facility or Office Visits
deductible
6* visits per 12 months
Not Applicable
Maximum Visits either in a group
or individual setting
*Important Note: Visits in excess of the Lactation Counseling Services Maximum as shown above, are covered
under the Physician Services office visit section of the Schedule of Benefits.
Breast Pumps & Supplies
100% per item
60% per item after Calendar Year
deductible
Important Note: Refer to the Comprehensive Lactation Support and Counseling Services section of the Benefit
Description-Certificate for limitations on breast pumps and supplies.
Family Planning Services
Female Contraceptive Counseling
Services -Office Visits.
100%per visit
deductible
Contraceptive Counseling Services
- Maximum Visits either in a group
41
Not Applicable
*Important Note: Visits in excess of the Contraceptive Counseling Services Maximum as shown above, are
covered under the Physician Services office visit section of the Schedule of Benefits.
Family Planning - Other
Voluntary Termination of Pregnancy
Outpatient
deductible.
Voluntary Sterilization for Males
Outpatient
deductible.
Family Planning - Female Voluntary Sterilization
100% per visit
Inpatient
deductible.
deductible.
deductible
Outpatient
100% per visit
deductible
PLAN FEATURES
Physician Services
Office Visits to Primary Care
Physician
Office visits (non-surgical) to
non-specialist
NETWORK
OUT-OF-NETWORK
deductible
deductible
Alternatives to Physicians' Office Visits
E-Visit Online Internet
Consultation by a PCP
deductible
Specialist Office Visits
deductible
Alternative to Specialist Office Visit
E-visits Online Internet
Consultation by a Specialist
deductible
42
Not Covered
deductible
Not Covered
Physician Office Visits-Surgery
deductible
Walk-In Clinic Visit (Non-Emergency)
Preventive Care Services*
Immunizations
100% per visit
deductible
deductible
Individual Screening and
Counseling Services for Tobacco
Use
100% per visit
deductible
Maximum Benefit per visit Individual Screening and
Use
Refer to the Preventive Care
Benefit section earlier in this
Schedule of Benefits for maximums
that may apply to these types of
services
services
Counseling Services for Obesity
100% per visit
deductible
services
services
*Important Note:
Not all preventive care services are available at all Walk-In Clinics. The types of services offered will vary by
the provider and location of the clinic. These services may also be obtained from your physician.
All Other Services
deductible
deductible
Physician Services for Inpatient
Facility and Hospital Visits
deductible
deductible
Administration of Anesthesia
80% per procedure after Calendar
Year deductible
Year deductible
43
Allergy Injections
deductible.
Immunizations
(when not part of the physical
exam)
Payable in accordance with the type Payable in accordance with the type
of expense incurred and the place
where service is provided.
PLAN FEATURES
Emergency Medical Services
Hospital Emergency Facility and
Physician
deductible.
NETWORK
OUT-OF-NETWORK
80% per visit after the Calendar
Year deductible
Year deductible
See Important Note Below
Important Note: Please note that as these providers are not network providers and do not have a contract with
Aetna, the provider may not accept payment of your cost share (your deductible and payment percentage), as
payment in full. You may receive a bill for the difference between the amount billed by the provider and the
amount paid by this Plan. If the Emergency Room Facility or physician bills you for an amount above your cost
share, you are not responsible for paying that amount. Please send us the bill at the address listed on the back of
your member ID card and we will resolve any payment dispute with the provider over that amount. Make sure
your member ID number is on the bill.
Not covered
Not covered
Urgent Care Services
Urgent Medical Care
(at a non-hospital free standing
facility)
deductible
deductible
Urgent Medical Care
(from other than a non-hospital
free standing facility)
Refer to Emergency Medical
Services and Physician Services
above.
above.
Non-Urgent Use of Urgent Care
Provider
(at an Emergency Room or a
non-hospital free standing facility)
Not covered
Not covered
Non-Emergency Care in a
Hospital Emergency Room
44
PLAN FEATURES
NETWORK
Outpatient Diagnostic and Preoperative Testing
Complex Imaging Services
Complex Imaging
OUT-OF-NETWORK
80% per test after Calendar Year
deductible
deductible
Year deductible
Year deductible
Diagnostic X-Rays (except Complex Imaging Services)
Diagnostic X-Rays
Year deductible
Year deductible
Diagnostic Laboratory Testing
PLAN FEATURES
Outpatient Surgery
Outpatient Surgery
NETWORK
OUT-OF-NETWORK
80% per visit/surgical procedure
after Calendar Year deductible
PLAN FEATURES
Inpatient Facility Expenses
Birthing Center
NETWORK
OUT-OF-NETWORK
Hospital Facility Expenses
Room and Board
(including maternity)
Other than Room and Board
80% per admission after Calendar
Year deductible
Year deductible
Year deductible
Year deductible
Skilled Nursing Inpatient Facility
Year deductible
Year deductible
Maximum Days per Calendar Year
120 days
120 days
45
PLAN FEATURES
Specialty Benefits
Home Health Care
(Outpatient)
NETWORK
OUT-OF-NETWORK
Year deductible
Year deductible
Maximum Visits per Calendar Year 120 visits
120 visits
Private Duty Nursing (Outpatient)
Year deductible
Year deductible
Maximum Visit Limit per Calendar
Year
Unlimited
Unlimited
Hospice Benefits
Hospice Care - Facility Expenses
(Room & Board)
Year deductible
Year deductible
Hospice Care - Other Expenses
during a stay
Year deductible
Year deductible
Maximum Benefit per lifetime
Unlimited days
Unlimited days
Hospice Outpatient Visits
deductible
deductible
PLAN FEATURES
NETWORK
Infertility Treatment
80% after Calendar Year
Basic Infertility Expenses
Coverage is for the diagnosis and
deductible
treatment of the underlying medical
condition causing the infertility
only.
OUT-OF-NETWORK
deductible
Comprehensive Infertility
Expenses
deductible
deductible
Advanced Reproductive
Technology (ART) Expenses
deductible
deductible
Maximum per lifetime*
$30,000*
$30,000*
*Does not apply toward the plan payment limit
46
PLAN FEATURES
NETWORK
Inpatient Treatment of Mental Disorders
OUT-OF-NETWORK
MENTAL DISORDERS
Room and Board
Year deductible
Year deductible
Year deductible
Year deductible
Physician Services
Year deductible
Year deductible
Inpatient Residential Treatment
Facility Expenses
Year deductible
Year deductible
Facility Expenses Physician
Services
deductible
deductible
Outpatient Treatment Of Mental Disorders
Outpatient Services
deductible
Year deductible
PLAN FEATURES
NETWORK
Inpatient Treatment of Substance Abuse
OUT-OF-NETWORK
Room and Board
Year deductible
Year deductible
Year deductible
Year deductible
Physician Services
Year deductible
Year deductible
47
Facility Expenses
Year deductible
Year deductible
Services
deductible
deductible
Outpatient Treatment of Substance Abuse
Outpatient Treatment
deductible
deductible
PLAN FEATURES
NETWORK
Obesity Treatment Non Surgical
Outpatient Obesity Treatment (non 80% per visit after the Calendar
Year deductible
surgical)
OUT-OF-NETWORK
PLAN FEATURES
Obesity Treatment Surgical
Inpatient Morbid Obesity Surgery
(includes Surgical procedure and
Acute Hospital Services)
NETWORK
OUT-OF-NETWORK
Year deductible
Year deductible
Outpatient Morbid Obesity
Surgery
80% per service after Calendar
Year deductible
Year deductible
Maximum Benefit Morbid Obesity
Surgery (Inpatient and Outpatient)
Unlimited
Unlimited
Year deductible
PLAN FEATURES
NETWORK
NETWORK
OUT-OF-NETWORK
(IOE Facility)
(Non-IOE Facility)
Transplant Services Facility and Non-Facility Expenses
80% per admission after
Transplant Facility
Calendar Year deductible Calendar Year deductible Calendar Year deductible
Expenses
Transplant Physician
Services
(including office visits)
Payable in accordance
with the type of expense
incurred and the place
where service is provided
48
PLAN FEATURES
Other Covered Health Expenses
NETWORK
OUT-OF-NETWORK
Acupuncture
deductible
deductible
Maximum per Calendar Year
30 visits
30 visits
Ground, Air or Water Ambulance
deductible
deductible
Durable Medical and Surgical
Equipment
80% per item after the Calendar
Year deductible
Year deductible
Jaw Joint Disorder Treatment
deductible
deductible
Oral and Maxillofacial Treatment
(Mouth, Jaws and Teeth)
Prosthetic Devices
deductible
deductible
PLAN FEATURES
Outpatient Therapies
NETWORK
OUT-OF-NETWORK
Chemotherapy
Infusion Therapy
Radiation Therapy
49
PLAN FEATURES
NETWORK
Short Term Outpatient Rehabilitation Therapies
Outpatient Physical, Occupational 80% per visit after Calendar Year
and Speech Therapy combined
deductible
OUT-OF-NETWORK
PLAN FEATURES
Spinal Manipulation
NETWORK
OUT-OF-NETWORK
deductible
deductible
30 visits
30 visits
Spinal Manipulation Maximum
visits per Calendar Year
deductible
Expense Provisions
The following provisions apply to your health expense plan.
This section describes cost sharing features, benefit maximums and other important provisions that apply to your
Plan.
Deductible Provisions
Covered expenses applied to the out-of-network provider deductibles will be applied to satisfy the network
provider deductibles. Covered expenses applied to the network provider deductibles will be applied to satisfy
the out-of-network provider deductibles.
All covered expenses accumulate toward the network provider and out-of-network provider deductibles
except for those covered expenses identified later in this Schedule of Benefits.
You and each of your covered dependents have separate Calendar Year deductibles. This Plan has individual and
family Calendar Year deductibles.
For purposes of Calendar Year deductible provision below, an individual means an employee enrolled for self only
coverage with no dependent coverage and a family means an employee enrolled with one or more dependents. The
family deductible can be met by one family member, or a combination of family members.
Network Provider Calendar Year Deductible
Individual
This is the amount of covered expenses that you incur each Calendar Year from a network provider for which no
benefits will be paid. After covered expenses reach this individual Calendar Year deductible, this Plan will begin
to pay benefits for covered expenses that you incur from a network provider for the rest of the Calendar Year.
Family
This is the amount of covered expenses that you and your covered dependents incur each Calendar Year from a
network provider for which no benefits will be paid. After covered expenses reach this family Calendar Year
deductible, this Plan will begin to pay benefits for covered expenses that you and your covered dependents incur
from a network provider for the rest of the Calendar Year.
50
Out-of-Network Provider Calendar Year Deductible
Individual
This is the amount of covered expenses that you incur each Calendar Year from an out-of-network provider for
which no benefits will be paid. This individual Calendar Year deductible applies separately to you. After covered
expenses reach this individual Calendar Year deductible; this Plan will begin to pay benefits for covered expenses
that you incur from an out-of-network provider for the rest of the Calendar Year.
Family
This is the amount of covered expenses that you and your covered dependents incur each Calendar Year from an
out-of-network provider for which no benefits will be paid. After covered expenses reach this family Calendar
Year deductible, this Plan will begin to pay benefits for covered expenses that you and your covered dependents
incur from an out-of-network provider for the rest of the Calendar Year.
Copayments and Benefit Deductible Provisions
Copayment, Copay
This is a specified dollar amount or percentage of the negotiated charge required to be paid by you at the time you
receive a covered service from a network provider. It represents a portion of the applicable expense.
Payment Provisions
Payment Percentage
This is the percentage of your covered expenses that the plan pays and the percentage of covered expenses that you
pay. The percentage that the plan pays is referred to as the “Plan Payment Percentage”. Once applicable deductibles
have been met, your plan will pay a percentage of the covered expenses, and you will be responsible for the rest of
the costs. The payment percentage may vary by the type of expense. Refer to your Schedule of Benefits for payment
percentage amounts for each covered benefit.
For purposes of the following coinsurance provisions, an individual means an employee enrolled for self only
coverage with no dependents coverage and a family means an employee enrolled with one or more dependents.
Maximum Out-of-Pocket Limit
The Maximum Out-of-Pocket Limit is the maximum amount you are responsible to pay for covered expenses
during the Calendar Year. This Plan has an individual and family Maximum Out-of-Pocket Limit.
Certain covered expenses do not apply toward the Maximum Out-of-Pocket Limit. See list below.
The Maximum Out-of-Pocket Limit applies to network provider and out-of-network provider benefits.
You have a separate Maximum Out-of-Pocket Limit for network provider and out-of-network provider
benefits. Covered expenses applied to the out-of-network Maximum Out-of-Pocket Limit will be applied to
satisfy the in-network Maximum Out-of-Pocket Limit and covered expenses applied to the in-network
Maximum Out-of-Pocket Limit will be applied to satisfy the out-of-network Maximum Out-of-Pocket Limit.
Network Provider Maximum Out-of-Pocket Limit
Individual
Once the amount of eligible network provider expenses you have paid during the Calendar Year meets the
individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward
the limit for the remainder of the Calendar Year for that person.
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Family
The Family Maximum Out-of-Pocket Limit can be met by a combination of family members or by any single
individual within the family. Once the amount of eligible network provider expenses paid during the Calendar Year
meets this family Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply
toward the limit for the remainder of the Calendar Year for all covered family members.
Out-of Network Provider Maximum Out-of-Pocket Limit
Individual
Once the amount of eligible out-of-network provider expenses you have paid during the Calendar Year meets the
individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that apply toward
the limit for the remainder of the Calendar Year for that person.
Family
The Family Maximum Out-of-Pocket Limit can be met by a combination of family members or by any single
individual within the family. Once the amount of eligible out-of-network provider expenses paid during the Calendar
Year meets this family Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered expenses that
apply toward the limit for the remainder of the Calendar Year for all covered family members.
Expenses That Do Not Apply to Your Out-of-Pocket Limit
Certain covered expenses do not apply toward your plan out-of-pocket limit. These include:
 Charges over the recognized charge;
 Non-covered expenses;
 Expenses for non-emergency use of the emergency room;
 Expenses incurred for non-urgent use of an urgent care provider; and
 Expenses that are not paid, or precertification benefit reductions because a required precertification for the
service(s) or supply was not obtained from Aetna.
Precertification Benefit Reduction
The Benefit Description contains a complete description of the precertification program. Refer to the
“Understanding Precertification” section for a list of services and supplies that require precertification.
Failure to precertify your covered expenses when required will result in a benefits reduction as follows:
 A $500 benefit reduction will be applied separately to each type of expense.
General
This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits.
Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot
be accepted. This Schedule is part of your Benefit Description and should be kept with your Benefit Description.
52
AETNA PPO PLAN
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Individual Deductible*
$500
$1,000
Family Deductible*
$1,500
$3,000
Calendar Year Deductible*
*Unless otherwise indicated, any applicable deductible must be met before benefits are paid.
Plan Maximum Out of Pocket Limit includes plan deductible and copayments.




person
Unlimited
Unlimited
Below.
PLAN FEATURES
Preventive Care Benefits
Office Visits
NETWORK
OUT-OF-NETWORK
100% per visit
deductible
53
Covered Persons through age 21: Subject to any age and visit limits
Maximum Age & Visit Limits
Administration.
Administration.
Covered Persons ages 22 but less 1 visit
than 65:
Year
1 visit
Covered Persons age 65 and
over:
Year
1 visit
1 visit
100% per visit
deductible
physician's office
Screening & Counseling Services - 100% per visits
Obesity, Misuse of Alcohol and/or
Drugs & Use of Tobacco Products No copay or deductible applies.
Obesity
chronic disease)*
80% per visits after Calendar Year
deductible
26 visits (however, of these only 10
Plan for healthy diet counseling
chronic disease)*
54
Year
5 visits*
5 visits*
8 visits*
Office Visits
100% per visit
deductible
applies.
Maximum Visits per Calendar Year 1 visit
Hearing Exam
1 visit
$25 exam copay then the plan pays
100%
60% per exam after Calendar Year
deductible
applies.
Maximum exams per 12 month
period
1 exam
1 exam
Hearing Supply Maximum per 36
month period
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Outpatient
100% per visit
deductible
applies.
55
Maximums
Prenatal Care
Office Visits
Administration.
Administration.
100% per visit
deductible.
100% per visit
deductible
Not Applicable
100% per item
60% per item after Calendar Year
deductible
Important Note: Refer to the Comprehensive Lactation Support and Counseling Services section of the Benefit
Description-Certificate for limitations on breast pumps and supplies.
100%per visit
deductible
Contraceptive Counseling Services
56
Not Applicable
Outpatient
deductible.
Outpatient
deductible.
100% per visit
Inpatient
deductible.
deductible.
deductible
Outpatient
100% per visit
deductible
PLAN FEATURES
Physician Services
Physician
non-specialist
NETWORK
OUT-OF-NETWORK
$25 visit copay then the plan pays
100%
deductible
applies.
100%
Not Covered
applies.
100%
applies.
57
deductible
100%
Not Covered
applies.
100%
deductible
applies.
Immunizations
100% per visit
deductible
Use
100% per visit
deductible
Use
services
services
100% per visit
deductible
services
services
*Important Note:
All Other Services
100%
58
deductible
applies.
deductible
deductible
Year deductible
Year deductible
Allergy Injections
deductible.
deductible.
Immunizations
(when not part of the physical
exam)
PLAN FEATURES
Physician
NETWORK
OUT-OF-NETWORK
Year deductible
Year deductible
See Important Note Below
Important Note: Please note that as these providers are not network providers and do not have a contract with
Aetna, the provider may not accept payment of your cost share (your deductible and payment percentage), as
payment in full. You may receive a bill for the difference between the amount billed by the provider and the
amount paid by this Plan. If the Emergency Room Facility or physician bills you for an amount above your cost
share, you are not responsible for paying that amount. Please send us the bill at the address listed on the back of
your member ID card and we will resolve any payment dispute with the provider over that amount. Make sure
your member ID number is on the bill.
Urgent Medical Care
facility)
Not covered
Not covered
$25 copay per visit then the plan
pays 100%
deductible
applies.
59
Urgent Medical Care
(from other than a non-hospital
free standing facility)
above.
above.
Provider
Not covered
Not covered
Important Notice:
A separate urgent care copay applies for each visit to an urgent care provider for urgent care.
Covered expenses that are applied to the urgent care copay cannot be applied to any other copay under your
plan. Likewise, covered expenses that are applied to your plan’s other copays cannot be applied to the urgent
care copay.
PLAN FEATURES
NETWORK
Complex Imaging
OUT-OF-NETWORK
80% per test
deductible
applies
80% per procedure
Year deductible
applies.
Diagnostic X-Rays (except Complex Imaging Services)
80% per procedure
Diagnostic X-Rays
applies.
60
Year deductible
PLAN FEATURES
Outpatient Surgery
Outpatient Surgery
NETWORK
OUT-OF-NETWORK
PLAN FEATURES
Birthing Center
NETWORK
OUT-OF-NETWORK
Room and Board
Year deductible
Year deductible
Year deductible
Year deductible
Year deductible
Year deductible
120 days
120 days
PLAN FEATURES
Specialty Benefits
Home Health Care
(Outpatient)
NETWORK
OUT-OF-NETWORK
Year deductible
Year deductible
120 visits
Year deductible
Year deductible
Year
Unlimited
Unlimited
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Hospice Benefits
Hospice Care - Facility Expenses
(Room & Board)
Year deductible
Year deductible
Hospice Care - Other Expenses
during a stay
Year deductible
Year deductible
Unlimited days
Unlimited days
deductible
deductible
PLAN FEATURES
NETWORK
deductible
only.
OUT-OF-NETWORK
deductible
Comprehensive Infertility
Expenses
deductible
deductible
Advanced Reproductive
Technology (ART) Expenses
deductible
deductible
Maximum per lifetime*
$30,000*
$30,000*
*Does not apply toward the Maximum Out-of-Pocket Limit
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
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MENTAL DISORDERS
Room and Board
Year deductible
Year deductible
Year deductible
Year deductible
Physician Services
Year deductible
Year deductible
Facility Expenses
Year deductible
Year deductible
Services
deductible
deductible
Outpatient Services
$25 per visit copay then the plan
pays 100%
Year deductible
applies
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Room and Board
Year deductible
Year deductible
Year deductible
Year deductible
Physician Services
Year deductible
Year deductible
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Facility Expenses
Year deductible
Year deductible
Services
deductible
deductible
pays 100%
deductible
applies
PLAN FEATURES
NETWORK
Outpatient Obesity Treatment (non 80% per visit after the Calendar
Year deductible
surgical)
OUT-OF-NETWORK
PLAN FEATURES
Obesity Treatment Surgical
NETWORK
OUT-OF-NETWORK
Year deductible
Year deductible
Surgery
Year deductible
Year deductible
Unlimited
Unlimited
Year deductible
PLAN FEATURES
NETWORK
NETWORK
OUT-OF-NETWORK
(IOE Facility)
(Non-IOE Facility)
Transplant Facility
Calendar Year deductible Calendar Year deductible Calendar Year deductible
Expenses
Services
64
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Acupuncture
pays 100%
deductible
applies
Maximum per Calendar Year
30 visits
30 visits
deductible
deductible
Equipment
Year deductible
Year deductible
deductible
deductible
Prosthetic Devices
deductible
deductible
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Chemotherapy
Infusion Therapy
Radiation Therapy
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PLAN FEATURES
NETWORK
Outpatient Physical, Occupational $25 per visit copay then the plan
pays 100%
and Speech Therapy combined
OUT-OF-NETWORK
deductible
applies
PLAN FEATURES
Spinal Manipulation
NETWORK
OUT-OF-NETWORK
pays 100%
deductible
applies.
30 visits
30 visits
Expense Provisions
Plan. The specific cost sharing features and the applicable dollar amounts or benefit percentages are contained in the
attached health expense sections of this Schedule of Benefits.
Covered expenses applied to the out-of-network provider deductibles will be applied to satisfy the network
provider deductibles. Covered expenses applied to the network provider deductibles will be applied to satisfy
the out-of-network provider deductibles.
All covered expenses accumulate toward the network provider and out-of-network provider deductibles
except for those covered expenses identified later in this Schedule of Benefits.
You and each of your covered dependents have separate Calendar Year deductibles. Each of you must meet your
deductible separately and they cannot be combined. This Plan has individual and family Calendar Year
deductibles.
Network Provider Calendar Year Deductible
Individual
This is the amount of covered expenses that you and each of your covered dependents incur each Calendar Year
from a network provider for which no benefits will be paid. This individual Calendar Year deductible applies
separately to you and each of your covered dependents. After covered expenses reach this individual Calendar Year
deductible, this Plan will begin to pay benefits for covered expenses that you incur from a network provider for
the rest of the Calendar Year.
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Family Deductible Limit
When you and each of your covered dependents incur covered expenses that apply towards the individual Calendar
Year deductibles, these expenses will also count toward a family deductible limit.
To satisfy this family deductible limit for the rest of the Calendar Year, the following must happen:
The combined covered expenses that you and each of your covered dependents incur towards the individual
Calendar Year deductibles must reach this family deductible limit in a Calendar Year.
When this occurs in a Calendar Year, the individual Calendar Year deductibles for you and your covered
dependents will be considered to be met for the rest of the Calendar Year.
Individual
from an out-of-network provider for which no benefits will be paid. This individual Calendar Year deductible
applies separately to you and each of your covered dependents. After covered expenses reach this individual
Calendar Year deductible; this Plan will begin to pay benefits for covered expenses that you incur from an
out-of-network provider for the rest of the Calendar Year.

The combined covered expenses that you and each of your covered dependents incur towards the individual
Calendar Year deductibles must reach this family deductible limit in a Calendar Year.
Copayment, Copay
Payment Provisions
during the Calendar Year. This Plan has an individual Maximum Out-of-Pocket Limit. As to the individual
Maximum Out-of-Pocket Limit, each of you must meet your Maximum Out-of-Pocket Limit separately and
they cannot be combined and applied towards one limit.
67
Individual
Once the amount of eligible network provider expenses you or your covered dependents have paid during the
Calendar Year meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered
expenses that apply toward the limit for the remainder of the Calendar Year for that person.
Family Maximum Out-of-Pocket Limit
Year network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family network
provider Maximum Out-of-Pocket Limit.
To satisfy this family network provider Maximum Out-of-Pocket Limit for the rest of the Calendar Year, the
following must happen:
The family Maximum Out-of-Pocket Limit is a cumulative Maximum Out-of-Pocket Limit for all family
members. The family network provider Maximum Out-of-Pocket Limit can be met by a combination of
family members with no single individual within the family contributing more than the individual network
provider Maximum Out-of-Pocket Limit amount in a Calendar Year.
Out-of Network Provider Maximum Out-of-Pocket Limit
Individual
Once the amount of eligible out-of-network provider expenses you or your covered dependents have paid during
the Calendar Year meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered
Year out-of-network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family
out-of-network provider Maximum Out-of-Pocket Limit.
To satisfy this family out-of-network provider Maximum Out-of-Pocket Limit for the rest of the Calendar Year,
the following must happen:
members. The family out-of-network provider Maximum Out-of-Pocket Limit can be met by a combination
of family members with no single individual within the family contributing more than the individual
out-of-network provider Maximum Out-of-Pocket Limit amount in a Calendar Year.
The Maximum Out-of-Pocket Limit applies to both network and out -of-network benefits. Covered expenses
applied to the out-of-network Maximum Out-of-Pocket Limit will be applied to satisfy the in-network Maximum
Out-of-Pocket Limit and covered expenses applied to the in-network Maximum Out-of-Pocket Limit will be
applied to satisfy the out-of-network Maximum Out-of-Pocket Limit.
Covered expenses that are subject to the Maximum Out-of-Pocket Limit include prescription drug expenses
provided under the Medical or Prescription drug Plans, as applicable.
68






Charges over the recognized charge;
Expenses incurred for outpatient prescription drugs;
Non-covered expenses;
Expenses for non-emergency use of the emergency room;
Expenses incurred for non-urgent use of an urgent care provider; and
Expenses that are not paid, or precertification benefit reductions because a required precertification for the
Precertification Benefit Reduction
The Benefit Description contains a complete description of the precertification program. Refer to the
“Understanding Precertification” section for a list of services and supplies that require precertification.
Failure to precertify your covered expenses when required will result in a benefits reduction as follows:

A $500 benefit reduction will be applied separately to each type of expense.
69
What Your Plan Covers and How Benefits Are Paid
Aetna Consumer Choice and PPO Plans
Preface
The medical benefits plan described in this Benefit Description is a benefit plan of the Employer. These benefits are
not insured with Aetna or any of its affiliates, but will be paid from the Employer's funds. Aetna and its HMO
affiliates will provide certain administrative services under the Aetna medical benefits plan.
Aetna agrees with the Employer to provide administrative services in accordance with the conditions, rights, and
privileges as set forth in this Benefit Description. The Employer selects the products and benefit levels under the
Aetna medical benefits plan.
The Benefit Description describes your rights and obligations, what the Aetna medical benefits plan covers, and
how benefits are paid for that coverage. It is your responsibility to understand the terms and conditions in this
Benefit Description. Your Benefit Description includes the Schedule of Benefits and any amendments.
This Benefit Description replaces and supercedes all Aetna Benefit Descriptions describing coverage for the
medical benefits plan described in this Benefit Description that you may previously have received.
Employer:
Contract Number:
Effective Date:
810072
January 1, 2015
Coverage for You and Your Dependents
Health Expense Coverage
Benefits are payable for covered health care expenses that are incurred by you or your covered dependents while
coverage is in effect. An expense is “incurred” on the day you receive a health care service or supply.
Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are
covered.
Refer to the What the Plan Covers section of the Benefit Description for more information about your coverage.
Treatment Outcomes of Covered Services
Aetna is not a provider of health care services and therefore is not responsible for and does not guarantee any results
or outcomes of the covered health care services and supplies you receive. Except for Aetna RX Home Delivery LLC,
providers of health care services, including hospitals, institutions, facilities or agencies, are independent contractors
and are neither agents nor employees of Aetna or its affiliates.
When the Coverage Begins
Throughout this section you will find information on who can be covered under the plan, how to enroll and what to
do when there is a change in your life that affects coverage. In this section, “you” means the employee.
70
Who Is Eligible
Employees
To be covered by this plan, the following requirements must be met:
 You will need to be in an “eligible class,” as defined below; and
 You will need to meet the “eligibility date criteria” described below.
Determining if You Are in an Eligible Class
You are in an eligible class if:
 You are a regular full-time employee, as defined by your employer.
Probationary Period
Once you enter an eligible class, you will need to complete the probationary period before your coverage under this
plan begins.
Determining When You Become Eligible
You become eligible for the plan on your eligibility date, which is determined as follows.
On the Effective Date of the Plan
If you are in an eligible class on the effective date of this plan, your coverage eligibility date is the effective date of
the plan.
After the Effective Date of the Plan
If you are hired or enter an eligible class after the effective date of this plan, your coverage eligibility date is the first
day of the month coinciding with or next following the date you complete 31 days of continuous service with your
employer. This is defined as the probationary period. If you had already satisfied the probationary period before you
entered the eligible class, your coverage eligibility date is the date you enter the eligible class.
Obtaining Coverage for Dependents
Your dependents can be covered under this Plan. You may enroll the following dependents:
 Your spouse.
 Your dependent children.
 Your domestic partner who meets the rules set by your employer.
 Dependent children of your domestic partner.
Aetna will rely upon your employer to determine whether or not a person meets the definition of a dependent for
coverage under this Plan. This determination will be conclusive and binding upon all persons for the purposes of
this Plan.
Coverage for a Domestic Partner
To be eligible for coverage, you and your domestic partner will need to complete and sign a Declaration of
Domestic Partnership.
Coverage for Dependent Children
To be eligible for coverage, a dependent child must be under 26 years of age.
An eligible dependent child includes:
 Your biological children;
 Your stepchildren;
 Your legally adopted children;
 Your foster children, including any children placed with you for adoption;
71



Any children for whom you are responsible under court order;
Your grandchildren in your court-ordered custody; and
Any other child with whom you have a parent-child relationship.
Coverage for a handicapped child may be continued past the age limits shown above. See Handicapped Dependent
Children for more information.
Important Reminder
Keep in mind that you cannot receive coverage under this Plan as:


Both an employee and a dependent; or
A dependent of more than one employee.
How and When to Enroll
Initial Enrollment in the Plan
You will be provided with plan benefit and enrollment information when you first become eligible to enroll. You
will need to enroll in a manner determined by Aetna and your employer. To complete the enrollment process, you
will need to provide all requested information for yourself and your eligible dependents. You will also need to agree
to make required contributions for any contributory coverage. Your employer will determine the amount of your
plan contributions, which you will need to agree to before you can enroll. Your employer will advise you of the
required amount of your contributions and will deduct your contributions from your pay. Remember plan
contributions are subject to change.
You will need to enroll within 31 days of your eligibility date. Otherwise, you may be considered a Late Enrollee. If
you miss the enrollment period, you will not be able to participate in the plan until the next annual enrollment period,
unless you qualify under a Special Enrollment Period, as described below.
If you do not enroll for coverage when you first become eligible, but wish to do so later, your employer will provide
you with information on when and how you can enroll.
Newborns are automatically covered for 31 days after birth. To continue coverage after 31 days, you will need to
complete a change form and return it to your employer within the 31-day enrollment period.
Late Enrollment
If you do not enroll during the Initial Enrollment Period, or a subsequent annual enrollment period, you and your
eligible dependents may be considered Late Enrollees and coverage may be deferred until the next annual
enrollment period. If, at the time of your initial enrollment, you elect coverage for yourself only and later request
coverage for your eligible dependents, they may be considered Late Enrollees.
You must return your completed enrollment form before the end of the next annual enrollment period as described
below.
However, you and your eligible dependents may not be considered Late Enrollees if you qualify for one of the
circumstances described in the “Special Enrollment Periods” section below.
Annual Enrollment
During the annual enrollment period, you will have the opportunity to review your coverage needs for the upcoming
year. During this period, you have the option to change your coverage. The choices you make during this annual
enrollment period will become effective the following year.
72
If you do not enroll yourself or a dependent for coverage when you first become eligible, but wish to do so later, you
will need to do so during the next annual enrollment period, unless you qualify under one of the Special Enrollment
Periods, as described below.
Special Enrollment Periods
You will not be considered a Late Enrollee if you qualify under a Special Enrollment Period as defined below. If
one of these situations applies, you may enroll before the next annual enrollment period.
Loss of Other Health Care Coverage
You or your dependents may qualify for a Special Enrollment Period if:



You did not enroll yourself or your dependent when you first became eligible or during any subsequent annual
enrollments because, at that time:
 You or your dependents were covered under other creditable coverage; and
 You refused coverage and stated, in writing, at the time you refused coverage that the reason was that you or
your dependents had other creditable coverage; and
You or your dependents are no longer eligible for other creditable coverage because of one of the following:
 The end of your employment;
 A reduction in your hours of employment (for example, moving from a full-time to part-time position);
 The ending of the other plan’s coverage;
 Death;
 Divorce or legal separation;
 Employer contributions toward that coverage have ended;
 COBRA coverage ends;
 The employer’s decision to stop offering the group health plan to the eligible class to which you belong;
 Cessation of a dependent’s status as an eligible dependent as such is defined under this Plan;
 With respect to coverage under Medicaid or an S-CHIP Plan, you or your dependents no longer qualify for
such coverage; or
 You or your dependents have reached the lifetime maximum of another Plan for all benefits under that Plan.
You or your dependents become eligible for premium assistance, with respect to coverage under the group
health plan, under Medicaid or an S-CHIP Plan.
You will need to enroll yourself or a dependent for coverage within:
 31 days of when other creditable coverage ends;
 within 60 days of when coverage under Medicaid or an S-CHIP Plan ends; or
 within 60 days of the date you or your dependents become eligible for Medicaid or S-CHIP premium assistance.
Evidence of termination of creditable coverage must be provided to your employer or the party it designates. If you
do not enroll during this time, you will need to wait until the next annual enrollment period.
New Dependents
You and your dependents may qualify for a Special Enrollment Period if:



You did not enroll when you were first eligible for coverage; and
You later acquire a dependent, as defined under the plan, through marriage, birth, adoption, or placement for
adoption; and
You elect coverage for yourself and your dependent within 31 days of acquiring the dependent.
73
Your spouse or child who meets the definition of a dependent under the plan may qualify for a Special Enrollment
Period if:
 You did not enroll them when they were first eligible; and
 You later elect coverage for them within 31 days of a court order requiring you to provide coverage.
You will need to report any new dependents by completing a change form, which is available from your employer.
The form must be completed and returned to your employer within 31 days of the change. If you do not return the
form within 31 days of the change, you will need to make the changes during the next annual enrollment period.
If You Adopt a Child
Your plan will cover a child who is placed for adoption. This means you have taken on the legal obligation for total
or partial support of a child whom you plan to adopt.
Your plan will provide coverage for a child who is placed with you for adoption if:




The child meets the plan’s definition of an eligible dependent on the date he or she is placed for adoption; and
You request coverage for the child in writing within 31 days of the placement;
Proof of placement will need to be presented to your employer prior to the dependent enrollment;
Any coverage limitations for a preexisting condition will not apply to a child placed with you for adoption
provided that the placement occurs on or after the effective date of your coverage.
When You Receive a Qualified Child Support Order
A Qualified Medical Child Support Order (QMCSO) is a court order requiring a parent to provide health care
coverage to one or more children. Your plan will provide coverage for a child who is covered under a QMCSO, if:


The child meets the plan’s definition of an eligible dependent; and
You request coverage for the child in writing within 31 days of the court order.
Coverage for the dependent will become effective on the date of the court order. Any coverage limitations for a
preexisting condition will not apply, as long as you submit a written request for coverage within the 31-day period.
If you do not request coverage for the child within the 31-day period, you will need to wait until the next annual
enrollment period.
Under a QMCSO, if you are the non-custodial parent, the custodial parent may file claims for benefits. Benefits for
such claims will be paid to the custodial parent.
When Your Coverage Begins
Your Effective Date of Coverage
If you have met all the eligibility requirements, your coverage takes effect on the later of:



The date you are eligible for coverage; and
The date your enrollment information is received; and
The date your required contribution is received by Aetna.
If your completed enrollment information is not received within 31 days of your eligibility date, the rules under the
Special or Late Enrollment Periods section will apply.
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Important Notice:
You must pay the required contribution in full or coverage will not be effective.
Your Dependent’s Effective Date of Coverage
Your dependent’s coverage takes effect on the same day that your coverage becomes effective, if you have enrolled
them in the plan.
Note: New dependents need to be reported to your employer within 31 days because they may affect your
contributions. If you do not report a new dependent within 31 days of his or her eligibility date, the rules under the
How the Medical Plan Works
It is important that you have the information and useful resources to help you get the most out of your Aetna
medical plan. This Benefit Description explains:
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Definitions you need to know;
How to access care, including procedures you need to follow;
What expenses for services and supplies are covered and what limits may apply;
What expenses for services and supplies are not covered by the plan;
How you share the cost of your covered services and supplies; and
Other important information such as eligibility, complaints and appeals, termination, continuation of coverage,
and general administration of the plan.
Important Notes
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Unless otherwise indicated, “you” refers to you and your covered dependents.
Your health plan pays benefits only for services and supplies described in this Benefit Description as covered
expenses that are medically necessary.
This Benefit Description applies to coverage only and does not restrict your ability to receive health care
services that are not or might not be covered benefits under this health plan.
Store this Benefit Description in a safe place for future reference.
Common Terms
Many terms throughout this Benefit Description are defined in the Glossary section at the back of this document.
Defined terms appear in bolded print. Understanding these terms will also help you understand how your plan works
and provide you with useful information regarding your coverage.
About Your Aetna Consumer Choice and PPO Medical Plan
This Aetna Consumer Choice and PPO (commonly referred to by Aetna as “Choice POS II plan”) medical plans
provide coverage for a wide range of medical expenses for the treatment of illness or injury. It does not provide
benefits for all medical care. The plan also provides coverage for certain preventive and wellness benefits. With
your Aetna Choice POS II plan, you can directly access any network or out-of-network physician, hospital or
other health care provider for covered services and supplies under the plan. The plan pays benefits differently when
services and supplies are obtained through network providers or out-of-network providers under this plan.
Important Note
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Network providers have contracted with Aetna, an affiliate or third party vendor to provide health care services
and supplies to Aetna plan members. Network providers are generally identified in the printed directory and the
on-line version of the directory via DocFind at www.aetna.com unless otherwise noted in this section.
Out-of-network providers are not listed in the Aetna directory.
The plan will pay for covered expenses up to the maximum benefits shown in this Benefit Description.
Coverage is subject to all the terms, policies and procedures outlined in this Benefit Description. Not all medical
expenses are covered under the plan. Exclusions and limitations apply to certain medical services, supplies and
expenses. Refer to the What the Plan Covers, Exclusions, Limitations sections and Schedule of Benefits to determine
if medical services are covered, excluded or limited.
This Aetna Choice POS II plan provides access to covered benefits through a broad network of health care providers
and facilities. This Aetna Choice POS II plan is designed to lower your out-of-pocket costs when you use network
providers for covered expenses. Your deductibles, copayments, and payment percentage will generally be
lower when you use network providers and facilities.
You also have the choice to access licensed providers, hospitals and facilities outside the network for covered
services and supplies. Your out-of-pocket costs will generally be higher when you use out-of-network providers
because the deductibles, copayments, and payment percentage that you are required to pay are usually higher
when you utilize out-of-network providers. Out-of-network providers have not agreed to accept the negotiated
charge and may balance bill you for charges over the amount Aetna pays under the plan.
Some services and supplies may only be covered through network providers. Refer to the Covered Benefit sections
and your Schedule of Benefits to determine if any services are limited to network coverage only.
Your out-of-pocket costs may vary between network and out-of-network benefits. Read your Schedule of Benefits
carefully to understand the cost sharing charges applicable to you.
Availability of Providers
Aetna cannot guarantee the availability or continued participation of a particular provider. Either Aetna or any
network provider may terminate the provider contract or limit the number of patients accepted in a practice. If the
physician initially selected cannot accept additional patients, you will be notified and given an opportunity to make
another selection.
Ongoing Reviews
Aetna conducts ongoing reviews of those services and supplies which are recommended or provided by health
professionals to determine whether such services and supplies are covered expenses under this Benefit Description.
If Aetna determines that the recommended services or supplies are not covered expenses, you will be notified. You
may appeal such determinations by contacting Aetna to seek a review of the determination. Please refer to the
Reporting of Claims and the Claims and Appeals sections of this Benefit Description.
To better understand the choices that you have with your Aetna Choice POS II plan, please carefully review the
following information.
How Your Aetna Consumer Choice and PPO Medical Plans Work
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The Primary Care Physician:
To access network benefits, you are encouraged to select a Primary Care Physician (PCP) from Aetna’s network
of providers at the time of enrollment. Each covered family member may select his or her own PCP. If your covered
dependent is a minor, or otherwise incapable of selecting a PCP, you should select a PCP on their behalf.
You may search online for the most current list of participating providers in your area by using DocFind, Aetna’s
online provider directory at www.aetna.com. You can choose a PCP based on geographic location, group practice,
medical specialty, language spoken, or hospital affiliation. DocFind is updated several times a week. You may also
request a printed copy of the provider directory through your employer or by contacting Member Services through
e-mail or by calling the toll free number on your ID card.
A PCP may be a general practitioner, family physician, internist, or pediatrician. Your PCP provides routine
preventive care and will treat you for illness or injury.
A PCP coordinates your medical care, as appropriate either by providing treatment or may direct you to other
network providers for other covered services and supplies. The PCP can also order lab tests and x-rays, prescribe
medicines or therapies, and arrange hospitalization.
Changing Your PCP
You may change your PCP at any time on Aetna’s website, www.aetna.com, or by calling the Member Services
toll-free number on your identification card. The change will become effective upon Aetna’s receipt and approval
of the request.
Specialists and Other Network Providers
You may directly access specialists and other health care professionals in the network for covered services and
supplies under this Benefit Description. Refer to the Aetna provider directory to locate network specialists,
providers and hospitals in your area. Refer to the Schedule of Benefits section for benefit limitations and
out-of-pocket costs applicable to your plan.
Important Note
ID Card: You will receive an ID card. It identifies you as a member when you receive services from health care
providers. If you have not received your ID card or if your card is lost or stolen, notify Aetna immediately and a
new card will be issued.
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Accessing Network Providers and Benefits
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You may select a PCP or other direct access network provider from the network provider directory or by
logging on to Aetna’s website at www.aetna.com. You can search Aetna’s online directory, DocFind, for
names and locations of physicians, hospitals and other health care providers and facilities. You can change
your PCP at anytime.
If a service or supply you need is covered under this Plan but not available from a network provider in your
area, your PCP may refer you to an out-of-network provider. As long as your PCP has provided you with a
referral that has been approved by Aetna, you will receive the network benefit level as shown in your Schedule
of Benefits.
area, please contact Member Services by email or at the toll-free number on your ID card for assistance.
Certain health care services such as hospitalization, outpatient surgery and certain other outpatient services,
require precertification with Aetna to verify coverage for these services. You do not need to precertify
services provided by a network provider. Network providers will be responsible for obtaining necessary
precertification for you. Since precertification is the provider’s responsibility, there are no additional
out-of-pocket costs to you as a result of a network provider’s failure to precertify services. Refer to the
Understanding Precertification section for more information on the precertification process and what to do if
your request for precertification is denied.
Except for your prescription drug expenses, you will not have to submit medical claims for treatment received
from network health care professionals and facilities. Your network provider will take care of claim
submission. Aetna will directly pay the network provider or facility less any cost sharing required by you.
You will be responsible for deductibles, payment percentage and copayments, if any.
You may be required to pay some network providers at the time of service. When you pay a network
provider directly, you will be responsible for completing a claim form to receive reimbursement of covered
expenses from Aetna. You must submit a completed claim form and proof of payment to Aetna. Refer to the
General Provisions section of this Benefit Description for a complete description of how to file a claim under
this Plan.
You will receive notification of what the plan has paid toward your covered expenses. It will indicate any
amounts you owe towards your deductible, copayments, or payment percentage or other non-covered
expenses you have incurred. You may elect to receive this notification by e-mail, or through the mail. Call or
e-mail Member Services if you have questions regarding your statement.
Cost Sharing For Network Benefits
You share in the cost of your benefits. Cost Sharing amounts and provisions are described in the Schedule of
Benefits.
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Network providers have agreed to accept the negotiated charge. Aetna will reimburse you for a covered
expense, incurred from a network provider, up to the negotiated charge and the maximum benefits under this
Plan, less any cost sharing required by you such as deductibles, copayments and payment percentage. Your
payment percentage is based on the negotiated charge. You will not have to pay any balance bills above the
negotiated charge for that covered service or supply.
You must satisfy any applicable deductibles before the plan will begin to pay benefits.
Deductibles and payment percentage are usually lower when you use network providers than when you use
out-of-network providers.
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For certain types of services and supplies, you will be responsible for any copayments shown in your Schedule
of Benefits. The copayments will vary depending upon the type of service and whether you obtain covered
health care services from a provider who is a specialist or non-specialist. You will be subject to the PCP
copayments shown on the Schedule of Benefits when you obtain covered health care services from any PCP
who is a network provider. If the provider is a network specialist, then the specialist copayment will apply.
After you satisfy any applicable deductible, you will be responsible for any applicable payment percentage
for covered expenses that you incur. You will be responsible for your payment percentage up to the
maximum out-of-pocket limit applicable to your plan.
Once you satisfy any applicable maximum out-of-pocket limit, the plan will pay 100% of the covered
expenses that apply toward the limits for the rest of the Calendar Year. Certain designated out-of-pocket
expenses may not apply to the maximum out-of-pocket limits. Refer to your Schedule of Benefits for
information on what covered expenses do not apply to the maximum out-of-pocket limits and for the specific
maximum out-of-pocket limit amounts that apply to your plan.
The plan will pay for covered expenses, up to the benefit maximums shown in the What the Plan Covers
section or the Schedule of Benefits. You are responsible for any expenses incurred over the maximum limits
outlined in the What the Plan Covers section or the Schedule of Benefits.
You may be billed for any deductible, copayment, or payment percentage amounts, or any non-covered
expenses that you incur.
Accessing Out-of-Network Providers and Benefits
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Certain health care services such as hospitalization, outpatient surgery and certain other outpatient services,
require precertification with Aetna to verify coverage for these services. When you receive services from an
out-of-network provider, you are responsible for obtaining the necessary precertification from Aetna. Your
provider may precertify the services for you. However, you should verify with Aetna prior to the service, that
the provider has obtained precertification from Aetna. If the service is not precertified, the benefit payable
may be significantly reduced or may not be covered. This means you will be responsible for the unpaid balance
of any bills. You must call the precertification toll-free number on your ID card to precertify services. Refer to
the Understanding Precertification section for more information on the precertification process and what to do
if your request for precertification is denied.
When you use out-of-network providers, you may have to pay for services at the time they are rendered. You
may be required to pay the full charges and submit a claim form to Aetna for reimbursement. You are
responsible for completing and submitting claim forms for reimbursement of covered expenses that you paid
directly to an out-of-network provider.
When you pay an out-of-network provider directly, you will be responsible for completing a claim form to
receive reimbursement of covered expenses from Aetna. You must submit a completed claim form and proof
of payment to Aetna. Refer to the General Provisions section of this Benefit Description for a complete
description of how to file a claim under this plan.
amounts you owe towards any deductible, or payment percentage amounts or other non-covered expenses
you have incurred. You may elect to receive this notification by e-mail, or through the mail. Call or e-mail
Member Services if you have questions regarding your statement.
Important Note
Failure to precertify services and supplies will result in a reduction of benefits or no coverage for the services or
supplies under this Benefit Description. Please refer to the Understanding Precertification section for information
on how to request precertification.
Cost Sharing for Out-of-Network Benefits
Benefits.
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Out-of-network providers have not agreed to accept the negotiated charge. Aetna will reimburse you for a
covered expense, incurred from an out-of network provider, up to the recognized charge and the maximum
benefits under this Plan, less any cost-sharing required by you such as deductibles and payment percentage.
The recognized charge is the maximum amount Aetna will pay for a covered expense from an
out-of-network provider. Your payment percentage is based on the recognized charge. If your
out-of-network provider charges more than the recognized charge, you will be responsible for any expenses
incurred above the recognized charge. Except for emergency services, Aetna will only pay up to the
recognized charge.
You must satisfy any applicable deductibles before the plan begins to pay benefits.
Deductibles and payment percentage are usually higher when you use out-of network providers than when
you use network providers.
maximum out-of-pocket limits that apply to your plan.
expenses may not apply to the maximum out-of-pocket limit. Refer to your Schedule of Benefits for
Understanding Precertification
Precertification
Certain services, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification
by Aetna. Precertification is a process that helps you and your physician determine whether the services being
recommended are covered expenses under the plan. It also allows Aetna to help your provider coordinate your
transition from an inpatient setting to an outpatient setting (called discharge planning), and to register you for
specialized programs or case management when appropriate.
You do not need to precertify services provided by a network provider. Network providers will be responsible
for obtaining necessary precertification for you. Since precertification is the provider’s responsibility, there is no
additional out-of-pocket cost to you as a result of a network provider’s failure to precertify services.
When you go to an out-of-network provider, it is your responsibility to obtain precertification from Aetna for
any services or supplies on the precertification list below. If you do not precertify, your benefits may be reduced,
or the plan may not pay any benefits. The list of services requiring precertification follows on the next page.
Important Note
Please read the following sections in their entirety for important information on the precertification process, and
any impact it may have on your coverage.
The Precertification Process
Prior to being hospitalized or receiving certain other medical services or supplies there are certain precertification
procedures that must be followed.
You or a member of your family, a hospital staff member, or the attending physician, must notify Aetna to
precertify the admission or medical services and expenses prior to receiving any of the services or supplies that
require precertification pursuant to this Benefit Description in accordance with the following timelines:
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Precertification should be secured within the timeframes specified below. To obtain precertification, call Aetna
at the telephone number listed on your ID card. This call must be made:
For non-emergency admissions:
For an emergency outpatient medical condition:
For an emergency admission:
For an urgent admission:
For outpatient non-emergency medical services
requiring precertification:
You, your physician or the facility will need to call
and request precertification at least 14 days before
the date you are scheduled to be admitted.
You or your physician should call prior to the
outpatient care, treatment or procedure if possible; or
as soon as reasonably possible.
You, your physician or the facility must call within 48
hours or as soon as reasonably possible after you have
been admitted.
You, your physician or the facility will need to call
before you are scheduled to be admitted. An urgent
admission is a hospital admission by a physician due
to the onset of or change in an illness; the diagnosis of
an illness; or an injury.
You or your physician must call at least 14 days
before the outpatient care is provided, or the treatment
or procedure is scheduled.
Aetna will provide a written notification to you and your physician of the precertification decision. If your
precertified expenses are approved the approval is good for 60 days as long as you remain enrolled in the plan.
When you have an inpatient admission to a facility, Aetna will notify you, your physician and the facility about
your precertified length of stay. If your physician recommends that your stay be extended, additional days will
need to be certified. You, your physician, or the facility will need to call Aetna at the number on your ID card as
soon as reasonably possible, but no later than the final authorized day. Aetna will review and process the request for
an extended stay. You and your physician will receive a notification of an approval or denial.
If precertification determines that the stay or services and supplies are not covered expenses, the notification will
explain why and how Aetna’s decision can be appealed. You or your provider may request a review of the
precertification decision pursuant to the Claims and Appeals section included with this Benefit Description.
Services and Supplies Which Require Precertification
Precertification is required for the following types of medical expenses:
Inpatient and Outpatient Care
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Stays in a hospital;
Stays in a skilled nursing facility;
Stays in a rehabilitation facility;
Stays in a hospice facility;
Outpatient hospice care;
Stays in a Residential Treatment Facility for treatment of mental disorders and substance abuse;
Partial Hospitalization Programs for mental disorders and substance abuse;
Home health care;
Private duty nursing care;
Intensive Outpatient Programs for mental disorders and substance abuse;
Amytal interview;
Applied Behavioral Analysis;
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Biofeedback;
Electroconvulsive therapy;
Neuropsychological testing;
Outpatient detoxification;
Psychiatric home care services;
Psychological testing.
How Failure to Precertify Affects Your Benefits
A precertification benefit reduction will be applied to the benefits paid if you fail to obtain a required
precertification prior to incurring medical expenses. This means Aetna will reduce the amount paid towards your
coverage, or your expenses may not be covered. You will be responsible for the unpaid balance of the bills.
You are responsible for obtaining the necessary precertification from Aetna prior to receiving services from an
out-of-network provider. Your provider may precertify your treatment for you; however you should verify with
Aetna prior to the procedure, that the provider has obtained precertification from Aetna. If your treatment is not
precertified by you or your provider, the benefit payable may be significantly reduced or your expenses may not be
covered.
How Your Benefits are Affected
The chart below illustrates the effect on your benefits if necessary precertification is not obtained.
If precertification is:
 requested and approved by Aetna.
 requested and denied.
 not requested, but would have been covered if
requested.
 not requested, would not have been covered if
requested.
then the expenses are:
 covered.
 not covered, may be appealed.
 covered after a precertification benefit reduction
is applied.*
 not covered, may be appealed.
It is important to remember that any additional out-of-pocket expenses incurred because your precertification
requirement was not met will not count toward your deductible or payment limit or maximum out-of-pocket
limit.
*Refer to the Schedule of Benefits section for the amount of precertification benefit reduction that applies to your
plan.
Emergency and Urgent Care
You have coverage 24 hours a day, 7 days a week, anywhere inside or outside the plan’s service area, for:
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An emergency medical condition; or
An urgent condition.
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In Case of a Medical Emergency
When emergency care is necessary, please follow the guidelines below:
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Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and
ambulatory assistance. If possible, call your physician provided a delay would not be detrimental to your
health.
After assessing and stabilizing your condition, the emergency room should contact your physician to obtain
your medical history to assist the emergency physician in your treatment.
If you are admitted to an inpatient facility, notify your physician as soon as reasonably possible.
If you seek care in an emergency room for a non-emergency condition, the plan will not cover the expenses you
incur. Please refer to the Schedule of Benefits for specific details about the plan. No other plan benefits will pay
for non-emergency care in the emergency room unless otherwise specified under the plan.
Coverage for Emergency Medical Conditions
Refer to Coverage for Emergency Medical Conditions in the What the Plan Covers section.
Important Reminder
If you visit a hospital emergency room for a non-emergency condition, the plan will not cover your expenses, as
shown in the Schedule of Benefits. No other plan benefits will pay for non-emergency care in the emergency room
unless otherwise specified under the Plan.
In Case of an Urgent Condition
Call your PCP if you think you need urgent care. Network providers are required to provide urgent care coverage
24 hours a day, including weekends and holidays. You may contact any physician or urgent care provider, in- or
out-of-network, for an urgent care condition if you cannot reach your physician.
If it is not feasible to contact your physician, please do so as soon as possible after urgent care is provided. If you
need help finding an urgent care provider you may call Member Services at the toll-free number on your I.D. card,
or you may access Aetna’s online provider directory at www.aetna.com.
Coverage for an Urgent Condition
Refer to Coverage for Urgent Medical Conditions in the What the Plan Covers section.
Non-Urgent Care
If you seek care from an urgent care provider for a non-urgent condition, (one that does not meet the criteria
above), the plan will not cover the expenses you incur unless otherwise specified under the Plan. Please refer to the
Schedule of Benefits for specific plan details.
Important Reminder
If you visit an urgent care provider for a non-urgent condition, the plan will not cover your expenses, as shown in
the Schedule of Benefits. No other plan benefits will pay for non-urgent care received at a hospital or an urgent care
provider unless otherwise specified.
Follow-Up Care After Treatment of an Emergency or Urgent Medical Condition
Follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or
urgent care visit. Once you have been treated and discharged, you should contact your physician for any necessary
follow-up care.
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For coverage purposes, follow-up care is treated as any other expense for illness or injury. If you access a hospital
emergency room for follow-up care, your expenses will not be covered and you will be responsible for the entire
cost of your treatment. Refer to your Schedule of Benefits for cost sharing information applicable to your plan.
To keep your out-of-pocket costs lower, your follow-up care should be provided by a physician.
You may use an out-of-network provider for your follow-up care. You will be subject to the deductible and
payment percentage that apply to out-of-network expenses, which may result in higher out-of-pocket costs to you.
Important Notice
Follow up care, which includes (but is not limited to) suture removal, cast removal and radiological tests such as
x-rays, should not be provided by an emergency room facility.
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Requirements For Coverage
To be covered by the plan, services and supplies must meet all of the following requirements:
1. The service or supply must be covered by the plan. For a service or supply to be covered, it must:
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Be included as a covered expense in this Benefit Description;
Not be an excluded expense under this Benefit Description. Refer to the Exclusions sections of this Benefit
Description for a list of services and supplies that are excluded;
Not exceed the maximums and limitations outlined in this Benefit Description. Refer to the What the Plan
Covers section and the Schedule of Benefits for information about certain expense limits; and
Be obtained in accordance with all the terms, policies and procedures outlined in this Benefit Description.
2. The service or supply must be provided while coverage is in effect. See the Who Can Be Covered, How and
When to Enroll, When Your Coverage Begins, When Coverage Ends and Continuation of Coverage sections for
details on when coverage begins and ends.
3. The service or supply must be medically necessary. To meet this requirement, the medical services or supply
must be provided by a physician, or other health care provider, exercising prudent clinical judgment, to a
patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its
symptoms. The provision of the service or supply must be:
(a) In accordance with generally accepted standards of medical practice;
(b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for
the patient’s illness, injury or disease; and
(c) Not primarily for the convenience of the patient, physician or other health care provider;
(d) And not more costly than an alternative service or sequence of services at least as likely to produce
equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury,
or disease.
For these purposes “generally accepted standards of medical practice” means standards that are based on credible
scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical
community, or otherwise consistent with physician specialty society recommendations and the views of physicians
practicing in relevant clinical areas and any other relevant factors.
Important Note
Not every service or supply that fits the definition for medical necessity is covered by the plan. Exclusions and
limitations apply to certain medical services, supplies and expenses. For example some benefits are limited to a
certain number of days, visits or a dollar maximum. Refer to the What the Plan Covers section and the Schedule of
Benefits for the plan limits and maximums.
What the Plan Covers
Aetna Consumer Choice and PPO Medical Plan
Many preventive and routine medical expenses as well as expenses incurred for a serious illness or injury are
covered. This section describes which expenses are covered expenses. Only expenses incurred for the services and
supplies shown in this section are covered expenses. Limitations and exclusions apply.
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Preventive Care
This section on Preventive Care describes the covered expenses for services and supplies provided when you are
well.
Covered expenses include charges made by your physician for routine physical exams. This includes routine
vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given
by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also
includes:
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Evidence-based items that have in effect a rating of A or B in the current recommendations of the United
States Preventive Services Task Force.
Screenings and counseling services as provided for in the comprehensive guidelines recommended by the
Health Resources and Services Administration. These services may include but are not limited to:
- Screening and counseling services, such as:
▫ Interpersonal and domestic violence;
▫ Sexually transmitted diseases; and
▫ Human Immune Deficiency Virus (HIV) infections.
- Screening for gestational diabetes for women.
- High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older.
X-rays, lab and other tests given in connection with the exam.
For covered newborns, an initial hospital check up.
Limitations:
Unless specified above, not covered under this Preventive Care benefit are charges for:
• Services which are covered to any extent under any other part of this Plan;
• Services which are for diagnosis or treatment of a suspected or identified illness or injury;
• Exams given during your stay for medical care;
• Services not given by a physician or under his or her direction;
• Psychiatric, psychological, personality or emotional testing or exams;
Covered expenses include charges made by your physician or a facility for:
 immunizations for infectious diseases; and
 the materials for administration of immunizations;
that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention.
Limitations
Not covered under this Preventive Care benefit are charges incurred for immunizations that are not considered
Preventive Care such as those required due to your employment or travel.
Covered expenses include charges made by your physician for a routine well woman preventive exam office visit,
including Pap smears, in accordance with the recommendations by the Health Resources and Services
Administration. A routine well woman preventive exam is a medical exam given by a physician for a reason other
than to diagnose or treat a suspected or identified illness or injury.
Limitations:
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•
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Services which are covered to any extent under any other part of this Plan;
Services which are for diagnosis or treatment of a suspected or identified illness or injury;
Exams given during your stay for medical care;
Services not given by a physician or under his or her direction;
Psychiatric, psychological, personality or emotional testing or exams.
Covered expenses include, but are not limited to, charges incurred for routine cancer screening as follows:
 Mammograms;
 Fecal occult blood tests;
 Digital rectal exams;
 Prostate specific antigen (PSA) tests;
 Sigmoidoscopies;
 Double contrast barium enemas (DCBE); and
 Colonoscopies.
These benefits will be subject to any age; family history; and frequency guidelines that are:
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Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United
States Preventive Services Task Force; and
Evidence-informed items or services provided in the comprehensive guidelines supported by the Health
Resources and Services Administration.
Limitations:
Unless specified above, not covered under this Preventive Care benefit are charges incurred for:
 Services which are covered to any extent under any other part of this Plan.
Important Notes:
Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Preventive Care.
For details on the frequency and age limits that apply to Routine Physical Exams and Routine Cancer Screenings,
contact your physician, log onto the Aetna website www.aetna.com, or call the member services at the number on
the back of your ID card.
Screening and Counseling Services
Covered expenses include charges made by your primary care physician in an individual or group setting for the
following:
Obesity
Screening and counseling services to aid in weight reduction due to obesity. Coverage includes:
 preventive counseling visits and/or risk factor reduction intervention;
 medical nutrition therapy;
 nutrition counseling; and
 healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known
risk factors for cardiovascular and diet-related chronic disease.
Benefits for the screening and counseling services above are subject to the visit maximums shown in your Schedule
of Benefits. In figuring the visit maximums, each session of up to 60 minutes is equal to one visit.
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Screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled
substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured
assessment.
Screening and counseling services to aid in the cessation of the use of tobacco products. Tobacco product means a
substance containing tobacco or nicotine including: cigarettes, cigars; smoking tobacco; snuff; smokeless tobacco
and candy-like products that contain tobacco. Coverage includes:
 preventive counseling visits;
 treatment visits; and
 class visits;
to aid in the cessation of the use of tobacco products.
Limitations:
Unless specified above, not covered under this benefit are charges for:





Services which are covered to any extent under any other part of this plan;
Services which are for diagnosis or treatment of a suspected or identified illness or injury;
Exams given during your stay for medical care;
Services not given by a physician or under his or her direction;
Psychiatric, psychological, personality or emotional testing or exams.
Prenatal Care
Prenatal care will be covered as Preventive Care for services received by a pregnant female in a physician's,
obstetrician's, or gynecologist's office but only to the extent described below.
Coverage for prenatal care under this Preventive Care benefit is limited to pregnancy-related physician office visits
including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood
pressure and fetal heart rate check).
Limitations:


Services which are covered to any extent under any other part of this Plan;
Pregnancy expenses (other than prenatal care as described above).
Important Notes:
Refer to the Pregnancy Expenses and Exclusions sections of this Benefit Description for more information on
coverage for pregnancy expenses under this Plan, including other prenatal care, delivery and postnatal care office
visits.
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Covered expenses include comprehensive lactation support (assistance and training in breast feeding) and
counseling services provided to females during pregnancy and in the post partum period by a certified lactation
support provider. The "post partum period" means the one-year period directly following the child's date of birth.
Covered expenses incurred during the post partum period also include the rental or purchase of breast feeding
equipment as described below.
Lactation support and lactation counseling services are covered expenses when provided in either a group or
individual setting. Benefits for lactation counseling services are subject to the visit maximum shown in your
Schedule of Benefits.
Breast Feeding Durable Medical Equipment
Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation
support (pumping and storage of breast milk) as follows.
Breast Pump
Covered expenses include the following:
 The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a
hospital.
 The purchase of:
- An electric breast pump (non-hospital grade). A purchase will be covered once every three years; or
- A manual breast pump. A purchase will be covered once every three years.
 If an electric breast pump was purchased within the previous three year period, the purchase of an electric or
manual breast pump will not be covered until a three year period has elapsed from the last purchase of an
electric pump.
Breast Pump Supplies
Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for
the purchase of a new pump.
Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar
purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire cost of any
additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility.
Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of
service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of
Aetna.
Limitations:
Unless specified above, not covered under this Preventive Care benefit are charges incurred for services which are
covered to any extent under any other part of this Plan.
Important Notes:
If a breast pump service or supply that you need is covered under this Plan but not available from a network
provider in your area, please contact Member Services at the toll-free number on your ID card for assistance.
Family Planning Services - Female Contraceptives
For females with reproductive capacity, covered expenses include those charges incurred for services and supplies
that are provided to prevent pregnancy. All contraceptive methods, services and supplies covered under this
Preventive Care benefit must be approved by the U.S. Food and Drug Administration (FDA).
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Coverage includes counseling services on contraceptive methods provided by a physician, obstetrician or
gynecologist. Such counseling services are covered expenses when provided in either a group or individual setting.
They are subject to the contraceptive counseling services visit maximum shown in your Schedule of Benefits.
The following contraceptive methods are covered expenses under this Preventive Care benefit:
Voluntary Sterilization
Covered expenses include charges billed separately by the provider for female voluntary sterilization procedures
and related services and supplies including, but not limited to, tubal ligation and sterilization implants.
Covered expenses under this Preventive Care benefit would not include charges for a voluntary sterilization
procedure to the extent that the procedure was not billed separately by the provider or because it was not the primary
purpose of a confinement.
Contraceptives
Covered expenses include charges made by a physician for:
 Female contraceptives that are brand name and generic prescription drugs;
 Female contraceptive devices including the related services and supplies needed to administer the device.
Limitations:
 Services which are covered to any extent under any other part of this Plan;
 Services and supplies incurred for an abortion;
 Services which are for the treatment of an identified illness or injury;
 Services that are not given by a physician or under his or her direction;
 Psychiatric, psychological, personality or emotional testing or exams;
 Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA;
 Male contraceptive methods, sterilization procedures or devices;
 The reversal of voluntary sterilization procedures, including any related follow-up care.
Family Planning Services - Other
Covered expenses include charges for certain family planning services, even though not provided to treat an illness
or injury.


Voluntary sterilization for males
Voluntary termination of pregnancy
Limitations:
Not covered are:
 Reversal of voluntary sterilization procedures, including related follow-up care;
 Charges for services which are covered to any extent under any other part of this Plan or any other group plans
sponsored by your employer; and
 Charges incurred for family planning services while confined as an inpatient in a hospital or other facility for
medical care.
Important Notes:
Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Family Planning
Services - Other. For more information, see the sections on Family Planning Services - Female Contraceptives,
Pregnancy Expenses and Treatment of Infertility in this Benefit Description.
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Hearing Exam
Covered expenses include charges for an audiometric hearing exam if the exam is performed by:


A physician certified as an otolaryngologist or otologist; or
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
 Performs the exam at the written direction of a legally qualified otolaryngologist or otologist.
The plan will not cover expenses for charges for more than one hearing exam for any 12-month period.
All covered expenses for the hearing exam are subject to any applicable deductible, copay and payment
percentage shown in your Schedule of Benefits.
Physician Services
Physician Visits
Covered medical expenses include charges made by a physician during a visit to treat an illness or injury. The visit
may be at the physician’s office, in your home, in a hospital or other facility during your stay or in an outpatient
facility. Covered expenses also include:
 Immunizations for infectious disease, but not if solely for your employment;
 Allergy testing, treatment and injections; and
 Charges made by the physician for supplies, radiological services, x-rays, and tests provided by the physician.
Surgery
 Performing your surgical procedure;
 Pre-operative and post-operative visits; and
 Consultation with another physician to obtain a second opinion prior to the surgery.
Anesthetics
Covered expenses include charges for the administration of anesthetics and oxygen by a physician, other than the
operating physician, or Certified Registered Nurse Anesthetist (C.R.N.A.) in connection with a covered procedure.
Important Reminder
Certain procedures need to be precertified by Aetna. Refer to How the Plan Works for more information about
precertification.
Alternatives to Physician Office Visits
Walk-In Clinic Visits
Covered expenses include charges made by walk-in clinics for:
 Unscheduled, non-emergency illnesses and injuries;
 The administration of certain immunizations administered within the scope of the clinic’s license; and
 Individual screening and counseling services to aid you:
 to stop the use of tobacco products;
 in weight reduction due to obesity.
Unless specified above, not covered under this benefit are charges incurred for services and supplies furnished:
 In a group setting for screening and counseling services.
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Important Note:
 Not all services are available at all Walk-In Clinics. The types of services offered will vary by the provider and
location of the clinic.
 For a complete description of the screening and counseling services provided on the use of tobacco products and
to aid in weight reduction due to obesity, refer to the Preventive Care Benefits section in this Benefit
Description and the Screening and Counseling Services benefit for a description of these services. These
services may also be obtained from your physician
E-Visits
Covered expenses include charges made by your network primary care physician (PCP) for a routine,
non-emergency, medical consultation. You must make your E-visit through an Aetna authorized internet service
vendor. You may have to register with that internet service vendor. Information about providers who are signed up
with an authorized vendor may be found in the provider Directory or online in DocFind on www.Aetna.com or by
calling the number on your identification card.
Hospital Expenses
Covered medical expenses include services and supplies provided by a hospital during your stay.
Room and Board
Covered expenses include charges for room and board provided at a hospital during your stay. Private room
charges that exceed the hospital’s semi-private room rate are not covered unless a private room is required
because of a contagious illness or immune system problem.
Room and board charges also include:
 Services of the hospital’s nursing staff;
 Admission and other fees;
 General and special diets; and
 Sundries and supplies.
Other Hospital Services and Supplies
Covered expenses include charges made by a hospital for services and supplies furnished to you in connection
with your stay.
Covered expenses include hospital charges for other services and supplies provided, such as:
 Ambulance services.
 Physicians and surgeons.
 Operating and recovery rooms.
 Intensive or special care facilities.
 Administration of blood and blood products, but not the cost of the blood or blood products.
 Radiation therapy.
 Speech therapy, physical therapy and occupational therapy.
 Oxygen and oxygen therapy.
 Radiological services, laboratory testing and diagnostic services.
 Medications.
 Intravenous (IV) preparations.
 Discharge planning.
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Outpatient Hospital Expenses
Covered expenses include hospital charges made for covered services and supplies provided by the outpatient
department of a hospital.
Important Reminders
The plan will only pay for nursing services provided by the hospital as part of its charge. The plan does not cover
private duty nursing services as part of an inpatient hospital stay.
If a hospital or other health care facility does not itemize specific room and board charges and other charges,
Aetna will assume that 40 percent of the total is for room and board charge, and 60 percent is for other charges.
Hospital admissions need to be precertified by Aetna. Refer to How the Plan Works for details about
precertification.
In addition to charges made by the hospital, certain physicians and other providers may bill you separately during
your stay.
Refer to the Schedule of Benefits for any applicable deductible, copay and payment percentage and maximum
benefit limits.
Covered expenses include charges made by a hospital or a physician for services provided in an emergency room
to evaluate and treat an emergency medical condition.
The emergency care benefit covers:
 Use of emergency room facilities;
 Emergency room physicians services;
 Hospital nursing staff services; and
 Radiologists and pathologists services.
Please contact your physician after receiving treatment for an emergency medical condition.
Important Reminder
With the exception of Urgent Care described below, if you visit a hospital emergency room for a non-emergency
condition, the plan will not cover your expenses, as shown in the Schedule of Benefits. No other plan benefits will
pay for non-emergency care in the emergency room.
Coverage for Urgent Conditions
Covered expenses include charges made by a hospital or urgent care provider to evaluate and treat an urgent
condition.
Your coverage includes:





Use of emergency room facilities when network urgent care facilities are not in the service area and you cannot
reasonably wait to visit your physician;
Use of urgent care facilities;
Physicians services;
Nursing staff services; and
Radiologists and pathologists services.
Please contact your PCP after receiving treatment of an urgent condition.
93
the Schedule of Benefits.
Alternatives to Hospital Stays
Outpatient Surgery and Physician Surgical Services
Covered expenses include charges for services and supplies furnished in connection with outpatient surgery made
by:
 A physician or dentist for professional services;
 A surgery center; or
 The outpatient department of a hospital.
The surgery must meet the following requirements:


The surgery can be performed adequately and safely only in a surgery center or hospital and
The surgery is not normally performed in a physician’s or dentist’s office.
Important Note
Benefits for surgery services performed in a physician's or dentist's office are described under Physician Services
benefits in the previous section.
The following outpatient surgery expenses are covered:
 Services and supplies provided by the hospital, surgery center on the day of the procedure;
 The operating physician’s services for performing the procedure, related pre- and post-operative care, and
administration of anesthesia; and
 Services of another physician for related post-operative care and administration of anesthesia. This does not
include a local anesthetic.
Limitations
Not covered under this plan are charges made for:
 The services of a physician or other health care provider who renders technical assistance to the operating
physician.
 A stay in a hospital.
 Facility charges for office based surgery.
Birthing Center
Covered expenses include charges made by a birthing center for services and supplies related to your care in a
birthing center for:
 Prenatal care;
 Delivery; and
 Postpartum care within 48 hours after a vaginal delivery and 96 hours after a Cesarean delivery.
Limitations
Unless specified above, not covered under this benefit are charges:
 In connection with a pregnancy for which pregnancy related expenses are not included as a covered expense.
See Pregnancy Related Expenses for information about other covered expenses related to maternity care.
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Home Health Care
Covered expenses include charges made by a home health care agency for home health care, and the care:


Is given under a home health care plan;
Is given to you in your home while you are homebound.
Home health care expenses include charges for:





Part-time or intermittent care by an R.N. or by an L.P.N. if an R.N. is not available.
Part-time or intermittent home health aid services provided in conjunction with and in direct support of care by
an R.N. or an L.P.N.
Physical, occupational, and speech therapy.
Part-time or intermittent medical social services by a social worker when provided in conjunction with, and in
direct support of care by an R.N. or an L.P.N.
Medical supplies, prescription drugs and lab services by or for a home health care agency to the extent they
would have been covered under this plan if you had a hospital stay.
Benefits for home health care visits are payable up to the Home Health Care Maximum. Each visit by a nurse or
therapist is one visit.
In figuring the Calendar Year Maximum Visits, each visit of up to 4 hours is one visit.
This maximum will not apply to care given by an R.N. or L.P.N. when:


Care is provided within 10 days of discharge from a hospital or skilled nursing facility as a full-time inpatient;
and
Care is needed to transition from the hospital or skilled nursing facility to home care.
When the above criteria are met, covered expenses include up to 12 hours of continuous care by an R.N. or L.P.N.
per day.
Coverage for Home Health Care services is not determined by the availability of caregivers to perform them. The
absence of a person to perform a non-skilled or custodial care service does not cause the service to become covered.
If the covered person is a minor or an adult who is dependent upon others for non-skilled care (e.g. bathing, eating,
toileting), coverage for home health services will only be provided during times when there is a family member or
caregiver present in the home to meet the person’s non-skilled needs.
Limitations







Services or supplies that are not a part of the Home Health Care Plan.
Services of a person who usually lives with you, or who is a member of your or your spouse’s or your domestic
partner's family.
Services of a certified or licensed social worker.
Services for Infusion Therapy.
Transportation.
Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present.
Services that are custodial care.
95
Important Reminders
The plan does not cover custodial care, even if care is provided by a nursing professional, and family member or
other caretakers cannot provide the necessary care.
Home health care needs to be precertified by Aetna. Refer to How the Plan Works for details about
precertification.
Refer to the Schedule of Benefits for details about any applicable home health care visit maximums.
Private Duty Nursing
Covered expenses include private duty nursing provided by a R.N. or L.P.N. if the person's condition requires
skilled nursing care and visiting nursing care is not adequate. However, covered expenses will not include private
duty nursing for any shifts during a Calendar Year in excess of the Private Duty Nursing Care Maximum Shifts.
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
The plan also covers skilled observation for up to one four-hour period per day, for up to 10 consecutive days
following:





A change in your medication;
Treatment of an urgent or emergency medical condition by a physician;
The onset of symptoms indicating a need for emergency treatment;
Surgery;
An inpatient stay.
Limitations
 Nursing care that does not require the education, training and technical skills of a R.N. or L.P.N.
 Nursing care assistance for daily life activities, such as:
 Transportation;
 Meal preparation;
 Vital sign charting;
 Companionship activities;
 Bathing;
 Feeding;
 Personal grooming;
 Dressing;
 Toileting; and
 Getting in/out of bed or a chair.
 Nursing care provided for skilled observation.
 Nursing care provided while you are an inpatient in a hospital or health care facility.
 A service provided solely to administer oral medicine, except where law requires a R.N. or L.P.N. to administer
medicines.
Skilled Nursing Facility
Covered expenses include charges made by a skilled nursing facility during your stay for the following services
and supplies, up to the maximums shown in the Schedule of Benefits, including:



Room and board, up to the semi-private room rate. The plan will cover up to the private room rate if it is
needed due to an infectious illness or a weak or compromised immune system;
Use of special treatment rooms;
Radiological services and lab work;
96




Physical, occupational, or speech therapy;
Oxygen and other gas therapy;
Other medical services and general nursing services usually given by a skilled nursing facility (this does not
include charges made for private or special nursing, or physician’s services); and
Medical supplies.
Important Reminder
Refer to the Schedule of Benefits for details about any applicable skilled nursing facility maximums.
Admissions to a skilled nursing facility must be precertified by Aetna. Refer to Using Your Medical Plan for
details about precertification.
Limitations


Charges made for the treatment of:
 Drug addiction;
 Alcoholism;
 Senility;
 Mental retardation; or
 Any other mental illness; and
Daily room and board charges over the semi private rate.
Hospice Care
Covered expenses include charges made by the following furnished to you for hospice care when given as part of
a hospice care program.
Facility Expenses
The charges made by a hospital, hospice or skilled nursing facility for:


Room and Board and other services and supplies furnished during a stay for pain control and other acute and
chronic symptom management; and
Services and supplies furnished to you on an outpatient basis.
Outpatient Hospice Expenses
Covered expenses include charges made on an outpatient basis by a Hospice Care Agency for:
 Part-time or intermittent nursing care by a R.N. or L.P.N. for up to eight hours a day;
 Part-time or intermittent home health aide services to care for you up to eight hours a day.
 Medical social services under the direction of a physician. These include but are not limited to:
 Assessment of your social, emotional and medical needs, and your home and family situation;
 Identification of available community resources; and
 Assistance provided to you to obtain resources to meet your assessed needs.
 Physical and occupational therapy; and
 Consultation or case management services by a physician;
 Medical supplies;
 Prescription drugs;
 Dietary counseling; and
 Psychological counseling.
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Charges made by the providers below if they are not an employee of a Hospice Care Agency; and such Agency
retains responsibility for your care:
 A physician for a consultation or case management;
 A physical or occupational therapist;
 A home health care agency for:
 Physical and occupational therapy;
 Part time or intermittent home health aide services for your care up to eight hours a day;
 Medical supplies;
 Prescription drugs;
 Psychological counseling; and
 Dietary counseling.
Limitations
 Daily room and board charges over the semi-private room rate.
 Funeral arrangements.
 Pastoral counseling.
 Financial or legal counseling. This includes estate planning and the drafting of a will.
 Homemaker or caretaker services. These are services which are not solely related to your care. These include,
but are not limited to: sitter or companion services for either you or other family members; transportation;
maintenance of the house.
Important Reminders
Refer to the Schedule of Benefits for details about any applicable hospice care maximums.
Inpatient hospice care and home health care must be precertified by Aetna. Refer to How the Plan Works for
details about precertification.
Other Covered Health Care Expenses
Acupuncture
The plan covers charges made for acupuncture services provided by a physician, if the service is performed:
 As a form of anesthesia in connection with a covered surgical procedure; and
 To treat an illness, injury or to alleviate chronic pain.
Important Reminder
Refer to the Schedule of Benefits for details about any applicable acupuncture benefit maximum.
Ambulance Service
Covered expenses include charges made by a professional ambulance, as follows:
Ground Ambulance
Covered expenses include charges for transportation:
 To the first hospital where treatment is given in a medical emergency.
 From one hospital to another hospital in a medical emergency when the first hospital does not have the
required services or facilities to treat your condition.
 From hospital to home or to another facility when other means of transportation would be considered unsafe
due to your medical condition.
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

From home to hospital for covered inpatient or outpatient treatment when other means of transportation would
be considered unsafe due to your medical condition. Transport is limited to 100 miles.
When during a covered inpatient stay at a hospital, skilled nursing facility or acute rehabilitation hospital, an
ambulance is required to safely and adequately transport you to or from inpatient or outpatient medically
necessary treatment.
Air or Water Ambulance
Covered expenses include charges for transportation to a hospital by air or water ambulance when:
 Ground ambulance transportation is not available; and
 Your condition is unstable, and requires medical supervision and rapid transport; and
 In a medical emergency, transportation from one hospital to another hospital; when the first hospital does not
have the required services or facilities to treat your condition and you need to be transported to another
hospital; and the two conditions above are met.
Limitations
Not covered under this benefit are charges incurred to transport you:
 If an ambulance service is not required by your physical condition; or
 If the type of ambulance service provided is not required for your physical condition; or
 By any form of transportation other than a professional ambulance service.
Diagnostic and Preoperative Testing
Diagnostic Complex Imaging Expenses
The plan covers charges made on an outpatient basis by a physician, hospital or a licensed imaging or radiological
facility for complex imaging services to diagnose an illness or injury, including:
 C.A.T. scans;
 Magnetic Resonance Imaging (MRI);
 Positron Emission Tomography (PET) Scans; and
 Any other outpatient diagnostic imaging service costing over $500.
Complex Imaging Expenses for preoperative testing will be payable under this benefit.
Limitations
The plan does not cover diagnostic complex imaging expenses under this part of the plan if such imaging expenses
are covered under any other part of the plan.
Outpatient Diagnostic Lab Work and Radiological Services
Covered expenses include charges for radiological services (other than diagnostic complex imaging), lab services,
and pathology and other tests provided to diagnose an illness or injury. You must have definite symptoms that start,
maintain or change a plan of treatment prescribed by a physician. The charges must be made by a physician,
hospital or licensed radiological facility or lab.
Important Reminder
Refer to the Schedule of Benefits for details about any deductible, payment percentage and maximum that may
apply to outpatient diagnostic testing, and lab and radiological services.
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Outpatient Preoperative Testing
Prior to a scheduled covered surgery, covered expenses include charges made for tests performed by a hospital,
surgery center, physician or licensed diagnostic laboratory provided the charges for the surgery are covered
expenses and the tests are:
 Related to your surgery, and the surgery takes place in a hospital or surgery center;
 Completed within 14 days before your surgery;
 Performed on an outpatient basis;
 Covered if you were an inpatient in a hospital;
 Not repeated in or by the hospital or surgery center where the surgery will be performed.
 Test results should appear in your medical record kept by the hospital or surgery center where the surgery is
performed.
Limitations

If your tests indicate that surgery should not be performed because of your physical condition, the plan will pay
for the tests, however surgery will not be covered.
Important Reminder
Complex Imaging testing for preoperative testing is covered under the complex imaging section. Separate cost
sharing may apply. Refer to your Schedule of Benefits for information on cost sharing amounts for complex
imaging.
Durable Medical and Surgical Equipment (DME)
Covered expenses include charges by a DME supplier for the rental of equipment or, in lieu of rental:
The initial purchase of DME if:
 Long term care is planned; and
 The equipment cannot be rented or is likely to cost less to purchase than to rent.
Repair of purchased equipment. Maintenance and repairs needed due to misuse or abuse are not covered.
Replacement of purchased equipment if:
 The replacement is needed because of a change in your physical condition; and
 It is likely to cost less to replace the item than to repair the existing item or rent a similar item.
The plan limits coverage to one item of equipment, for the same or similar purpose and the accessories needed to
operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment
you purchase or rent for personal convenience or mobility.
Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the
Exclusions section of this Benefit Description. Aetna reserves the right to limit the payment of charges up to the
most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The
decision to rent or purchase is at the discretion of Aetna.
Important Reminder
Refer to the Schedule of Benefits for details about durable medical and surgical equipment deductible, payment
percentage and benefit maximums. Also refer to Exclusions for information about Home and Mobility exclusions.
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Experimental or Investigational Treatment
Covered expenses include charges made for experimental or investigational drugs, devices, treatments or
procedures, provided all of the following conditions are met:
 You have been diagnosed with cancer or a condition likely to cause death within one year or less;
 Standard therapies have not been effective or are inappropriate;
 Aetna determines, based on at least two documents of medical and scientific evidence, that you would likely
benefit from the treatment;
 There is an ongoing clinical trial. You are enrolled in a clinical trial that meets these criteria:
 The drug, device, treatment or procedure to be investigated has been granted investigational new drug (IND) or
Group c/treatment IND status;
 The clinical trial has passed independent scientific scrutiny and has been approved by an Institutional Review
Board that will oversee the investigation;
 The clinical trial is sponsored by the National Cancer Institute (NCI) or similar national organization (such as
the Food & Drug Administration or the Department of Defense) and conforms to the NCI standards;
 The clinical trial is not a single institution or investigator study unless the clinical trial is performed at an
NCI-designated cancer center; and
 You are treated in accordance with protocol.
Pregnancy Related Expenses
Covered expenses include charges made by a physician for pregnancy and childbirth services and supplies at the
same level as any illness or injury. This includes prenatal visits, delivery and postnatal visits.
For inpatient care of the mother and newborn child, covered expenses include charges made by a Hospital for a
minimum of:
 48 hours after a vaginal delivery; and
 96 hours after a cesarean section.
 A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn
earlier.
Covered expenses also include charges made by a birthing center as described under Alternatives to Hospital
Care.
Note: Covered expenses also include services and supplies provided for circumcision of the newborn during the
stay.
Prosthetic Devices
Covered expenses include charges made for internal and external prosthetic devices and special appliances, if the
device or appliance improves or restores body part function that has been lost or damaged by illness, injury or
congenital defect. Covered expenses also include instruction and incidental supplies needed to use a covered
prosthetic device.
The plan covers the first prosthesis you need that temporarily or permanently replaces all or part of a body part lost
or impaired as a result of disease or injury or congenital defects as described in the list of covered devices below for
an:
 Internal body part or organ; or
 External body part.
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Covered expenses also include replacement of a prosthetic device if:
 The replacement is needed because of a change in your physical condition; or normal growth or wear and tear;
or
 It is likely to cost less to buy a new one than to repair the existing one; or
 The existing one cannot be made serviceable.
The list of covered devices includes but is not limited to:
 An artificial arm, leg, hip, knee or eye;
 Eye lens;
 An external breast prosthesis and the first bra made solely for use with it after a mastectomy;
 A breast implant after a mastectomy;
 Ostomy supplies, urinary catheters and external urinary collection devices;
 Speech generating device;
 A cardiac pacemaker and pacemaker defibrillators; and
 A durable brace that is custom made for and fitted for you.
The plan will not cover expenses and charges for, or expenses related to:
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Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet; unless the orthopedic
shoe is an integral part of a covered leg brace; or
Trusses, corsets, and other support items; or
Any item listed in the Exclusions section.
Hearing Aids
Covered hearing care expenses include charges for electronic hearing aids (monaural and binaural), installed in
accordance with a prescription written during a covered hearing exam.
Benefits are payable up to the hearing supply maximum listed in the Schedule of Benefits.
All covered expenses are subject to the hearing expense exclusions in this Benefit Description- and are subject to
deductible(s), copayments or payment percentage listed in the Schedule of Benefits, if any.
Benefits After Termination of Coverage
Expenses incurred for hearing aids within 30 days of termination of the person’s coverage under this benefit section
will be deemed to be covered hearing care expenses if during the 30 days before the date coverage ends:
 The prescription for the hearing aid was written; and
 The hearing aid was ordered.
Autism Spectrum Disorders
Covered expenses include expenses incurred by a covered person for services for the diagnosis and treatment of
autism, including Applied Behavioral Analysis. Benefits are payable in the same way as those for any other
disease.
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Autism means:
 A developmental neurological disorder, appearing in the first three years of life, which affects normal brain
functions and is manifested by compulsive, ritualistic behavior and severely impaired social interaction and
communication skills.
Applied Behavioral Analysis is an educational service that is the process of applying interventions:
 That systematically change behavior; and
 That are responsible for the observable improvement in behavior.
Important Reminder
Refer to the Schedule of Benefits for details about any applicable copays, deductibles, coinsurance, and benefit
maximums.
Short-Term Rehabilitation Therapy Services
Covered expenses include charges for short-term therapy services when prescribed by a physician as described
below up to the benefit maximums listed on your Schedule of Benefits. The services have to be performed by:
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A licensed or certified physical, occupational or speech therapist;
A hospital, skilled nursing facility, or hospice facility;
A home health care agency; or
A physician.
Charges for the following short term rehabilitation expenses are covered:
Cardiac and Pulmonary Rehabilitation Benefits.
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Cardiac rehabilitation benefits are available as part of an inpatient hospital stay. A limited course of outpatient
cardiac rehabilitation is covered when following angioplasty, cardiovascular surgery, congestive heart failure or
myocardial infarction. The plan will cover charges in accordance with a treatment plan as determined by your
risk level when recommended by a physician. This course of treatment is limited to a maximum of 36 sessions
in a 12 week period.
Pulmonary rehabilitation benefits are available as part of an inpatient hospital stay. A limited course of
outpatient pulmonary rehabilitation is covered for the treatment of reversible pulmonary disease states. This
course of treatment is limited to a maximum of 36 hours or a six week period.
Outpatient Cognitive Therapy, Physical Therapy, Occupational Therapy and Speech
Therapy Rehabilitation Benefits.
Coverage is subject to the limits, if any, shown on the Schedule of Benefits. Inpatient rehabilitation benefits for the
services listed will be paid as part of your Inpatient Hospital and Skilled Nursing Facility benefits provision in this
Benefit Description.
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Physical therapy is covered for non-chronic conditions and acute illnesses and injuries, provided the therapy
expects to significantly improve, develop or restore physical functions lost or impaired as a result of an acute
illness, injury or surgical procedure. Physical therapy does not include educational training or services
designed to develop physical function. Coverage for physical therapy is available for the treatment of Autism
Spectrum Disorders (as an exception to the above non-chronic condition coverage criteria).
Occupational therapy (except for vocational rehabilitation or employment counseling) is covered for
non-chronic conditions and acute illnesses and injuries, provided the therapy expects to significantly improve,
develop or restore physical functions lost or impaired as a result of an acute illness, injury or surgical procedure,
or to relearn skills to significantly improve independence in the activities of daily living. Occupational therapy
does not include educational training or services designed to develop physical function. Coverage for
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occupational therapy is available for the treatment of Autism Spectrum Disorders (as an exception to the above
non-chronic condition coverage criteria).
Speech therapy is covered for non-chronic conditions and acute illnesses and injuries and expected to restore
the speech function or correct a speech impairment resulting from illness or injury; or for delays in speech
function development as a result of a gross anatomical defect present at birth. Speech function is the ability to
express thoughts, speak words and form sentences. Speech impairment is difficulty with expressing one’s
thoughts with spoken words. Coverage for speech therapy is available for the treatment of Autism Spectrum
Disorders (as an exception to the above non-chronic condition coverage criteria).
Cognitive therapy associated with physical rehabilitation is covered when the cognitive deficits have been
acquired as a result of neurologic impairment due to trauma, stroke, or encephalopathy, and when the therapy is
part of a treatment plan intended to restore previous cognitive function.
A “visit” consists of no more than one hour of therapy. Refer to the Schedule of Benefits for the visit maximum that
applies to the plan. Covered expenses include charges for two therapy visits of no more than one hour in a 24-hour
period.
The therapy should follow a specific treatment plan that:
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Details the treatment, and specifies frequency and duration; and
Provides for ongoing reviews and is renewed only if continued therapy is appropriate.
Allows therapy services, provided in your home, if you are homebound.
Important Reminder
Refer to the Schedule of Benefits for details about the short-term rehabilitation therapy maximum benefit.
Unless specifically covered above, not covered under this benefit are charges for:
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Therapies for the treatment of delays in development, unless resulting from acute illness or injury, or congenital
defects amenable to surgical repair (such as cleft lip/palate), are not covered (except as provided for the
treatment of Autism Spectrum Disorders). Examples of non-covered diagnoses include Pervasive
Developmental Disorders, Down's Syndrome, and Cerebral Palsy, as they are considered both developmental
and/or chronic in nature.
Any services which are covered expenses in whole or in part under any other group plan sponsored by an
employer;
Any services unless provided in accordance with a specific treatment plan;
Services for the treatment of delays in speech development, unless resulting from: illness; injury; or congenital
defect;
Services provided during a stay in a hospital, skilled nursing facility, or hospice facility except as stated
above;
Services not performed by a physician or under the direct supervision of a physician;
Treatment covered as part of the Spinal Manipulation Treatment. This applies whether or not benefits have been
paid under that section;
Services provided by a physician or physical, occupational or speech therapist who resides in your home; or
who is a member of your family, or a member of your spouse’s family; or your domestic partner;
Special education to instruct a person whose speech has been lost or impaired, to function without that ability.
This includes lessons in sign language.
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Reconstructive or Cosmetic Surgery and Supplies
Covered expenses include charges made by a physician, hospital, or surgery center for reconstructive services
and supplies, including:
 Surgery needed to improve a significant functional impairment of a body part.
 Surgery to correct the result of an accidental injury, including subsequent related or staged surgery, provided
that the surgery occurs no more than 24 months after the original injury. For a covered child, the time period for
coverage may be extended through age 18.
 Surgery to correct the result of an injury that occurred during a covered surgical procedure provided that the
reconstructive surgery occurs no more than 24 months after the original injury.
Note: Injuries that occur as a result of a medical (i.e., non surgical) treatment are not considered accidental injuries,
even if unplanned or unexpected.
 Surgery to correct a gross anatomical defect present at birth or appearing after birth (but not the result of an
illness or injury) when
 the defect results in severe facial disfigurement, or
 the defect results in significant functional impairment and the surgery is needed to improve function
Reconstructive Breast Surgery
Covered expenses include reconstruction of the breast on which a mastectomy was performed, including an
implant and areolar reconstruction. Also included is surgery on a healthy breast to make it symmetrical with the
reconstructed breast and physical therapy to treat complications of mastectomy, including lymphedema.
Important Notice
A benefit maximum may apply to reconstructive or cosmetic surgery services. Please refer to the Schedule of
Benefits.
Specialized Care
Chemotherapy
Covered expenses include charges for chemotherapy treatment. Coverage levels depend on where treatment is
received. In most cases, chemotherapy is covered as outpatient care. Inpatient hospitalization for chemotherapy is
limited to the initial dose while hospitalized for the diagnosis of cancer and when a hospital stay is otherwise
medically necessary based on your health status.
Radiation Therapy Benefits
Covered expenses include charges for the treatment of illness by x-ray, gamma ray, accelerated particles, mesons,
neutrons, radium or radioactive isotopes.
Outpatient Infusion Therapy Benefits
Covered expenses include charges made on an outpatient basis for infusion therapy by:
 A free-standing facility;
 The outpatient department of a hospital; or
 A physician in his/her office or in your home.
Infusion therapy is the intravenous or continuous administration of medications or solutions that are a part of your
course of treatment. Charges for the following outpatient Infusion Therapy services and supplies are covered
expenses:
 The pharmaceutical when administered in connection with infusion therapy and any medical supplies,
equipment and nursing services required to support the infusion therapy;
 Professional services;
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Total parenteral nutrition (TPN);
Chemotherapy;
Drug therapy (includes antibiotic and antivirals);
Pain management (narcotics); and
Hydration therapy (includes fluids, electrolytes and other additives).
Not included under this infusion therapy benefit are charges incurred for:
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Enteral nutrition;
Blood transfusions and blood products;
Dialysis; and
Insulin.
Coverage is subject to the maximums, if any, shown in the Schedule of Benefits.
Coverage for inpatient infusion therapy is provided under the Inpatient Hospital and Skilled Nursing Facility
Benefits sections of this Benefit Description.
Benefits payable for infusion therapy will not count toward any applicable Home Health Care maximums.
Important Reminder
Refer to the Schedule of Benefits for details on any applicable deductible, payment percentage and maximum
benefit limits.
Treatment of Infertility
Covered expenses include charges made by a physician to diagnose and to surgically treat the underlying medical
cause of infertility.
Comprehensive Infertility and Advanced Reproductive Technology (ART) Expenses
To be an eligible covered female for benefits you must be covered under this Benefit Description as an employee, or
be a covered dependent who is the employee's spouse.
Even though not incurred for treatment of an illness or injury, covered expenses will include expenses incurred by
an eligible covered female for infertility if all of the following tests are met:
 A condition that is a demonstrated cause of infertility which has been recognized by a gynecologist, or an
infertility specialist, and your physician who diagnosed you as infertile, and it has been documented in your
medical records.
 The procedures are done while not confined in a hospital or any other facility as an inpatient.
 Your FSH levels are less than, 19 miU on day 3 of the menstrual cycle.
 The infertility is not caused by voluntary sterilization of either one of the partners (with or without surgical
reversal); or a hysterectomy.
 A successful pregnancy cannot be attained through less costly treatment for which coverage is available under
this Benefit Description.
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Comprehensive Infertility Services Benefits
If you meet the eligibility requirements above, the following comprehensive infertility services expenses are
payable when provided by an infertility specialist upon pre-authorization by Aetna, subject to all the exclusions and
limitations of this Benefit Description:
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Ovulation induction with menotropins is subject to the maximum benefit, if any, shown in the Schedule of
Benefits section of this Benefit Description and has a maximum of 6 cycles per lifetime; (where lifetime is
defined to include services received, provided or administered by Aetna or any affiliated company of Aetna);
and
Intrauterine insemination is subject to the maximum benefit, if any, shown in the Schedule of Benefits section of
this Benefit Description and has a maximum of 6 cycles per lifetime; (where lifetime is defined to include
services received, provided or administered by Aetna or any affiliated company of Aetna).
Advanced Reproductive Technology (ART) Benefits
ART is defined as:
 In vitro fertilization (IVF);
 Zygote intrafallopian transfer (ZIFT);
 Gamete intra-fallopian transfer (GIFT);
 Cryopreserved embryo transfers;
 Intracytoplasmic sperm injection (ICSI); or ovum microsurgery.
ART services for procedures that are covered expenses under this Benefit Description.
Eligibility for ART Benefits
To be eligible for ART benefits under this Benefit Description, you must meet the requirements above and:
 First exhaust the comprehensive infertility services benefits. Coverage for ART services is available only if
comprehensive infertility services do not result in a pregnancy in which a fetal heartbeat is detected;
 Be referred by your physician to Aetna's infertility case management unit;
 Obtain pre-authorization from Aetna's infertility case management unit for ART services by an ART specialist.
Covered ART Benefits
The following charges are covered benefits for eligible covered females when all of the above conditions are met,
subject to the Exclusions and Limitations section of the Benefit Description:
 Up to 3 cycles and subject to the maximum benefit, if any, shown in the Schedule of Benefits section of any
combination of the following ART services per lifetime (where lifetime is defined to include all ART services
received, provided or administered by Aetna or any affiliated company of Aetna) which only include: IVF;
GIFT; ZIFT; or cryopreserved embryo transfers;
 IVF; Intra-cytoplasmic sperm injection (“ICSI”); ovum microsurgery; GIFT; ZIFT; or cryopreserved embryo
transfers subject to the maximum benefit shown on the Schedule of Benefits section while covered under an
Aetna plan;
 Payment for charges associated with the care of the an eligible covered person under this plan who is
participating in a donor IVF program, including fertilization and culture; and
 Charges associated with obtaining the spouse's sperm for ART, when the spouse is also covered under this
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Exclusions and Limitations
Unless otherwise specified above, the following charges will not be payable as covered expenses under this Benefit
Description:
 ART services for a female attempting to become pregnant who has not had at least 1 year or more of timed,
unprotected coitus, or 12 cycles of artificial insemination (for covered persons under 35 years of age), or 6
months or more of timed, unprotected coitus, or 6 cycles of artificial insemination (for covered persons 35 years
of age or older) prior to enrolling in the infertility program;
 ART services for couples in which 1 of the partners has had a previous sterilization procedure, with or without
surgical reversal;
 Reversal of sterilization surgery;
 Infertility services for females with FSH levels 19 or greater mIU/ml on day 3 of the menstrual cycle;
 The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any
charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or
surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational
carrier;
 Charges associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g., office, hospital,
ultrasounds, laboratory tests, etc.);
 Home ovulation prediction kits;
 Drugs related to the treatment of non-covered benefits;
 Injectable infertility medications, including but not limited to, menotropins, hCG, GnRH agonists, and IVIG;
 Any services or supplies provided without pre-authorization from Aetna’s infertility case management unit;
 Infertility Services that are not reasonably likely to result in success;
 Ovulation induction and intrauterine insemination services if you are not infertile.
Exclusions That Apply to Accidental Death and Personal Loss
Not all events which may be ruled accidental are covered by this plan. No benefits are payable for a loss caused or
contributed to by:
 Air or space travel. This does not apply if a person is a passenger, with no duties at all, on an aircraft being used
only to carry passengers (with or without cargo.)
 Bodily or mental infirmity.
 Commission of or attempting to commit a criminal act.
 Illness, ptomaine or bacterial infection.*
 Inhalation of poisonous gases.
 Intended or accidental contact with nuclear or atomic energy by explosion and/or release.
 Ligature strangulation resulting from auto-erotic asphyxiation.
 Intentionally self-inflicted injury.
 Medical or surgical treatment*.
 3rd degree burns resulting from sunburn.
 Use of alcohol.
 Use of drugs, except as prescribed by a physician.
 Use of intoxicants.
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Use of alcohol or intoxicants or drugs while operating any form of a motor vehicle whether or not registered for
land, air or water use. A motor vehicle accident will be deemed to be caused by the use of alcohol, intoxicants
or drugs if it is determined that at the time of the accident you or your covered dependent were:
 Operating the motor vehicle while under the influence of alcohol is a level which meets or exceeds the
level at which intoxication would be presumed under the laws of the state where the accident occurred. If
the accident occurs outside of the United States, intoxication will be presumed if the person’s blood alcohol
level meets or exceeds .08 grams per deciliter; or
 Operating the motor vehicle while under the influence of an intoxicant or illegal drug; or
 Operating the motor vehicle while under the influence of a prescription drug in excess of the amount
prescribed by the physician; or
 Operating the motor vehicle while under the influence of an over the counter medication taken in an
amount above the dosage instructions.
Suicide or attempted suicide (while sane or insane).
War or any act of war (declared or not declared).
* These do not apply if the loss is caused by:
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An infection which results directly from the injury.
Surgery needed because of the injury.
The injury must not be one which is excluded by the terms of this section.
Spinal Manipulation Treatment
Covered expenses include charges made by a physician on an outpatient basis for manipulative (adjustive)
treatment or other physical treatment for conditions caused by (or related to) biomechanical or nerve conduction
disorders of the spine.
Your benefits are subject to the maximum shown in the Schedule of Benefits. However, this maximum does not
apply to expenses incurred:
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During your hospital stay; or
For surgery. This includes pre- and post-surgical care provided or ordered by the operating physician.
The plan covers charges made by a physician, hospital or surgery center for the diagnosis and surgical treatment
of jaw joint disorder. A jaw joint disorder is defined as a painful condition:
 Of the jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome; or
 Involving the relationship between the jaw joint and related muscles and nerves such as myofacial pain
dysfunction (MPD).
Benefits are payable up to the jaw joint disorder maximum shown in the Schedule of Benefits.
Unless specified above, not covered under this benefit are charges for non-surgical treatment of a jaw joint
disorder.
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Transplant Services
Covered expenses include charges incurred during a transplant occurrence. The following will be considered to be
one transplant occurrence once it has been determined that you or one of your dependents may require an organ
transplant. Organ means solid organ; stem cell; bone marrow; and tissue.
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Heart;
Lung;
Heart/Lung;
Simultaneous Pancreas Kidney (SPK);
Pancreas;
Kidney;
Liver;
Intestine;
Bone Marrow/Stem Cell;
Multiple organs replaced during one transplant surgery;
Tandem transplants (Stem Cell);
Sequential transplants;
Re-transplant of same organ type within 180 days of the first transplant;
Any other single organ transplant, unless otherwise excluded under the plan.
The following will be considered to be more than one Transplant Occurrence:
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Autologous blood/bone marrow transplant followed by allogenic blood/bone marrow transplant (when not part
of a tandem transplant);
Allogenic blood/bone marrow transplant followed by an autologous blood/bone marrow transplant (when not
part of a tandem transplant);
Re-transplant after 180 days of the first transplant;
Pancreas transplant following a kidney transplant;
A transplant necessitated by an additional organ failure during the original transplant surgery/process;
More than one transplant when not performed as part of a planned tandem or sequential transplant, (e.g., a liver
transplant with subsequent heart transplant).
The network level of benefits is paid only for a treatment received at a facility designated by the plan as an Institute
of Excellence™ (IOE) for the type of transplant being performed. Each IOE facility has been selected to perform
only certain types of transplants.
Services obtained from a facility that is not designated as an IOE for the transplant being performed will be covered
as out-of-network services and supplies, even if the facility is a network facility or IOE for other types of services.
The plan covers:
 Charges made by a physician or transplant team.
 Charges made by a hospital, outpatient facility or physician for the medical and surgical expenses of a live
donor, but only to the extent not covered by another plan or program.
 Related supplies and services provided by the facility during the transplant process. These services and supplies
may include: physical, speech and occupational therapy; bio-medicals and immunosuppressants; home health
care expenses and home infusion services.
 Charges for activating the donor search process with national registries.
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Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this
coverage, an “immediate” family member is defined as a first-degree biological relative. These are your
biological parents, siblings or children.
Inpatient and outpatient expenses directly related to a transplant.
Covered transplant expenses are typically incurred during the four phases of transplant care described below.
Expenses incurred for one transplant during these four phases of care will be considered one transplant occurrence.
A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either 180 days
from the date of the transplant; or upon the date you are discharged from the hospital or outpatient facility for the
admission or visit(s) related to the transplant, whichever is later.
The four phases of one transplant occurrence and a summary of covered transplant expenses during each phase are:
1. Pre-transplant evaluation/screening: Includes all transplant-related professional and technical components
required for assessment, evaluation and acceptance into a transplant facility’s transplant program;
2. Pre-transplant/candidacy screening: Includes HLA typing/compatibility testing of prospective organ donors
who are immediate family members;
3. Transplant event: Includes inpatient and outpatient services for all covered transplant-related health services
and supplies provided to you and a donor during the one or more surgical procedures or medical therapies for a
transplant; prescription drugs provided during your inpatient stay or outpatient visit(s), including bio-medical
and immunosuppressant drugs; physical, speech or occupational therapy provided during your inpatient stay or
outpatient visit(s); cadaveric and live donor organ procurement; and
4. Follow-up care: Includes all covered transplant expenses; home health care services; home infusion services;
and transplant-related outpatient services rendered within 180 days from the date of the transplant event.
If you are a participant in the IOE program, the program will coordinate all solid organ and bone marrow
transplants and other specialized care you need. Any covered expenses you incur from an IOE facility will be
considered network care expenses.
Important Reminders
To ensure coverage, all transplant procedures need to be precertified by Aetna. Refer to the How the Plan Works
section for details about precertification.
Refer to the Schedule of Benefits for details about transplant expense maximums, if applicable.
Limitations
Unless specified above, not covered under this benefit are charges incurred for:
 Outpatient drugs including bio-medicals and immunosuppressants not expressly related to an outpatient
transplant occurrence;
 Services that are covered under any other part of this plan;
 Services and supplies furnished to a donor when the recipient is not covered under this plan;
 Home infusion therapy after the transplant occurrence;
 Harvesting or storage of organs, without the expectation of immediate transplantation for an existing illness;
 Harvesting and/or storage of bone marrow, tissue or stem cells, without the expectation of transplantation
within 12 months for an existing illness;
 Cornea (Corneal Graft with Amniotic Membrane) or Cartilage (autologous chondrocyte or autologous
osteochondral mosaicplasty) transplants, unless otherwise authorized by Aetna.
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Network of Transplant Specialist Facilities
Through the IOE network, you will have access to a provider network that specializes in transplants. Benefits may
vary if an IOE facility or non-IOE or out-of-network provider is used. In addition, some expenses are payable
only within the IOE network. The IOE facility must be specifically approved and designated by Aetna to perform
the procedure you require. Each facility in the IOE network has been selected to perform only certain types of
transplants, based on quality of care and successful clinical outcomes.
Obesity Treatment
Covered expenses include charges made by a physician, licensed or certified dietician, nutritionist or hospital for
the non-surgical treatment of obesity for the following outpatient weight management services:
 An initial medical history and physical exam;
 Diagnostic tests given or ordered during the first exam; and
 Prescription drugs.
Morbid Obesity Surgical Expenses
Covered medical expenses include charges made by a hospital or a physician for the surgical treatment of morbid
obesity of a covered person.
Coverage includes the following expenses as long as they are incurred within a two-year period:
 One morbid obesity surgical procedure including complications directly related to the surgery;
 Pre-surgical visits;
 Related outpatient services; and
 One follow-up visit.
This two-year period begins with the date of the first morbid obesity surgical procedure, unless a multi-stage
procedure is planned.
Complications, other than those directly related to the surgery, will be covered under the related medical plan's
covered medical expenses, subject to plan limitations and maximums.
Limitations
 Weight control services including surgical procedures, medical treatments, weight control/loss programs,
dietary regimens and supplements, food or food supplements, appetite suppressants and other medications;
exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to
control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of
the existence of comorbid conditions; except as provided in the Benefit Description; and.
Important Reminder
Refer to the Schedule of Benefits for information about any applicable benefit maximums that apply to morbid
obesity treatment.
Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth)
Covered expenses include charges made by a physician, a dentist and hospital for:
 Non-surgical treatment of infections or diseases of the mouth, jaw joints or supporting tissues.
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Services and supplies for treatment of, or related conditions of, the teeth, mouth, jaws, jaw joints or supporting
tissues, (this includes bones, muscles, and nerves), for surgery needed to:
 Treat a fracture, dislocation, or wound.
 Cut out teeth that are partly or completely impacted in the bone of the jaw; teeth that will not erupt through the
gum; other teeth that cannot be removed without cutting into bone; the roots of a tooth without removing the
entire tooth; cysts, tumors, or other diseased tissues.
 Cut into gums and tissues of the mouth. This is only covered when not done in connection with the removal,
replacement or repair of teeth.
 Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result
in functional improvement.
Hospital services and supplies received for a stay required because of your condition.
Dental work, surgery and orthodontic treatment needed to remove, repair, restore or reposition:
(a) Natural teeth damaged, lost, or removed; or
(b) Other body tissues of the mouth fractured or cut
due to injury.
Any such teeth must have been free from decay or in good repair, and are firmly attached to the jaw bone at the time
of the injury.
The treatment must be completed in the Calendar Year of the accident or in the next Calendar Year.
If crowns, dentures, bridges, or in-mouth appliances are installed due to injury, covered expenses only include
charges for:
 The first denture or fixed bridgework to replace lost teeth;
 The first crown needed to repair each damaged tooth; and
 An in-mouth appliance used in the first course of orthodontic treatment after the injury.
Transgender Reassignment (Sex Change) Surgery
Covered expenses include charges in connection with a medically necessary Transgender Reassignment
(sometimes called Sex Change) Surgery as per Aetna’s Clinical Policy Bulletin, which includes the medical
necessity criteria.
Covered expenses include:
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Charges made by a physician for:
• Performing the surgical procedure; and
• Pre-operative and post-operative hospital and office visits.
Charges made by a hospital for inpatient and outpatient services (including outpatient surgery). Room and
board charges in excess of the hospital’s semi-private rate will not be covered unless a private room is ordered
by your physician and precertification has been obtained.
Charges made by a Skilled Nursing Facility for inpatient services and supplies. Room and board charges in
excess of the hospital’s semi-private rate will not be covered.
Charges made for the administration of anesthetics.
Charges for outpatient diagnostic laboratory and x-rays.
Charges for blood transfusion and the cost of unreplaced blood and blood products. Also included are the
charges for collecting, processing and storage of self-donated blood after the surgery has been scheduled.
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Important Reminders
Certain services, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification
by Aetna. Please refer to the Understanding Precertification for important information on the precertification
process, and any impact it may have on your coverage.
Refer to the Schedule of Benefits for details about deductibles, coinsurance or benefit maximums.
Limitations:
Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction
of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery
(laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are
considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist
masculinization, are considered cosmetic.
Medical Plan Exclusions
Not every medical service or supply is covered by the plan, even if prescribed, recommended, or approved by your
physician or dentist. The plan covers only those services and supplies that are medically necessary and included in
the What the Plan Covers section. Charges made for the following are not covered except to the extent listed under
the What The Plan Covers section or by amendment attached to this Benefit Description.
Acupuncture, acupressure and acupuncture therapy, except as provided in the What the Plan Covers section.
Allergy: Specific non-standard allergy services and supplies, including but not limited to, skin titration (Rinkel
method), cytotoxicity testing (Bryan’s Test) treatment of non-specific candida sensitivity, and urine autoinjections.
Any charges in excess of the benefit, dollar, day, visit or supply limits stated in this Benefit Description.
Any non-emergency charges incurred outside of the United States if you traveled to such location to obtain
prescription drugs or supplies, even if otherwise covered under this Benefit Description. This also includes
prescription drugs or supplies if:


such prescription drugs or supplies are unavailable or illegal in the United States, or
the purchase of such prescription drugs or supplies outside the United States is considered illegal.
Applied Behavioral Analysis (except as provided for the treatment of Autism Spectrum Disorders), the
LEAP, TEACCH, Denver and Rutgers programs.
Behavioral Health Services:
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Alcoholism or substance abuse rehabilitation treatment on an inpatient or outpatient basis, except to the extent
coverage for detoxification or treatment of alcoholism or substance abuse is specifically provided in the What
the Medical Plan Covers Section.
Treatment of a covered health care provider who specializes in the mental health care field and who receives
treatment as a part of their training in that field.
Treatment of impulse control disorders such as pathological gambling, kleptomania, pedophilia, caffeine or
nicotine use.
Treatment of antisocial personality disorder.
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
Treatment in wilderness programs or other similar programs.
Treatment of mental retardation, defects, and deficiencies. This exclusion does not apply to mental health
services or to medical treatment of mentally retarded in accordance with the benefits provided in the What the
Plan Covers section of this Benefit Description.
Blood, blood plasma, synthetic blood, blood products or substitutes, including but not limited to, the provision
of blood, other than blood derived clotting factors. Any related services including processing, storage or
replacement costs, and the services of blood donors, apheresis or plasmapheresis are not covered. For autologous
blood donations, only administration and processing costs are covered.
Charges for a service or supply furnished by a network provider in excess of the negotiated charge.
Charges for a service or supply furnished by an out-of-network provider in excess of the recognized charge.
Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage under the
plan.
Charges submitted for services by an unlicensed hospital, physician or other provider or not within the scope of the
provider’s license.
Contraception, except as specifically described in the What the Plan Covers Section:

Over the counter contraceptive supplies including but not limited to condoms, contraceptive foams, jellies and
ointments.
Cosmetic services and plastic surgery: any treatment, surgery (cosmetic or plastic), service or supply to alter,
improve or enhance the shape or appearance of the body whether or not for psychological or emotional reasons
including:

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Face lifts, body lifts, tummy tucks, liposuctions, removal of excess skin, removal or reduction of non-malignant
moles, blemishes, varicose veins, cosmetic eyelid surgery and other surgical procedures;
Procedures to remove healthy cartilage or bone from the nose (even if the surgery may enhance breathing) or
other part of the body;
Chemical peels, dermabrasion, laser or light treatments, bleaching, creams, ointments or other treatments or
supplies to alter the appearance or texture of the skin;
Insertion or removal of any implant that alters the appearance of the body (such as breast or chin implants);
except removal of an implant will be covered when medically necessary;
Removal of tattoos (except for tattoos applied to assist in covered medical treatments, such as markers for
radiation therapy); and
Repair of piercings and other voluntary body modifications, including removal of injected or implanted
substances or devices;
Surgery to correct Gynecomastia;
Breast augmentation;
Otoplasty.
Counseling: Services and treatment for marriage, religious, family, career, social adjustment, pastoral, or financial
counselor except as specifically provided in the What the Plan Covers section.
Court ordered services, including those required as a condition of parole or release.
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Custodial Care
Dental Services: any treatment, services or supplies related to the care, filling, removal or replacement of teeth and
the treatment of injuries and diseases of the teeth, gums, and other structures supporting the teeth. This includes but
is not limited to:



services of dentists, oral surgeons, dental hygienists, and orthodontists including apicoectomy (dental root
resection), root canal treatment, soft tissue impactions, treatment of periodontal disease, alveolectomy,
augmentation and vestibuloplasty and fluoride and other substances to protect, clean or alter the appearance of
teeth;
dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth guards, and
other devices to protect, replace or reposition teeth; and
non-surgical treatments to alter bite or the alignment or operation of the jaw, including treatment of
malocclusion or devices to alter bite or alignment.
This exclusion does not include removal of bony impacted teeth, bone fractures, removal of tumors and
orthodontogenic cysts.
Disposable outpatient supplies: Any outpatient disposable supply or device, including sheaths, bags, elastic
garments, support hose, bandages, bedpans, syringes, blood or urine testing supplies, and other home test kits; and
splints, neck braces, compresses, and other devices not intended for reuse by another patient.
Drugs, medications and supplies:

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
Over-the-counter drugs, biological or chemical preparations and supplies that may be obtained without a
prescription including vitamins;
Any services related to the dispensing, injection or application of a drug;
Any prescription drug purchased illegally outside the United States, even if otherwise covered under this plan
within the United States;
Immunizations related to work;
Needles, syringes and other injectable aids, except as covered for diabetic supplies;
Drugs related to the treatment of non-covered expenses;
Performance enhancing steroids;
Injectable drugs if an alternative oral drug is available;
Outpatient prescription drugs;
Self-injectable prescription drugs and medications;
Any prescription drugs, injectibles, or medications or supplies provided by the customer or through a third
party vendor contract with the customer; and
Charges for any prescription drug for the treatment of erectile dysfunction, impotence, or sexual dysfunction or
inadequacy.
Educational services (except as provided for the treatment of Autism Spectrum Disorders):



Any services or supplies related to education, training or retraining services or testing, including: special
education, remedial education, job training and job hardening programs;
Evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental, learning and
communication disorders, behavioral disorders, (including pervasive developmental disorders) training or
cognitive rehabilitation, regardless of the underlying cause; and
Services, treatment, and educational testing and training related to behavioral (conduct) problems, learning
disabilities and delays in developing skills.
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Examinations:
 Any health examinations required:
 by a third party, including examinations and treatments required to obtain or maintain employment, or
which an employer is required to provide under a labor agreement;
 by any law of a government;
 for securing insurance, school admissions or professional or other licenses;
 to travel;
 to attend a school, camp, or sporting event or participate in a sport or other recreational activity; and
Any special medical reports not directly related to treatment except when provided as part of a covered service.
Experimental or investigational drugs, devices, treatments or procedures, except as described in the What the
Plan Covers section.
Facility charges for care services or supplies provided in:
 rest homes;
 assisted living facilities;
 similar institutions serving as an individual's primary residence or providing primarily custodial or rest care;
 health resorts;
 spas, sanitariums; or
 infirmaries at schools, colleges, or camps.
Food items: Any food item, including infant formulas, nutritional supplements, vitamins, including prescription
vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition. This exclusion does not
apply to specialized medical foods delivered enterally (only when delivered via a tube directly into the stomach or
intestines) or parenterally.
Foot care: Any services, supplies, or devices to improve comfort or appearance of toes, feet or ankles, including but
not limited to:
 Treatment of calluses, bunions, toenails, hammer-toes, subluxations, fallen arches, weak feet, chronic foot pain
or conditions caused by routine activities such as walking, running, working or wearing shoes; and
 Shoes (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards, protectors,
creams, ointments and other equipment, devices and supplies, even if required following a covered treatment of
an illness or injury.
Growth/Height: Any treatment, device, drug, service or supply (including surgical procedures, devices to stimulate
growth and growth hormones), solely to increase or decrease height or alter the rate of growth.
Hearing:
 Any hearing service or supply that does not meet professionally accepted standards;
 Hearing exams given during a stay in a hospital or other facility;
 Replacement parts or repairs for a hearing aid; and
 Any tests, appliances, and devices for the improvement of hearing (including hearing aids and amplifiers), or to
enhance other forms of communication to compensate for hearing loss or devices that simulate speech, except
as otherwise provided under the What the Plan Covers section.
Home and mobility: Any addition or alteration to a home, workplace or other environment, or vehicle and any
related equipment or device, such as:
 Purchase or rental of exercise equipment, air purifiers, central or unit air conditioners, water purifiers,
waterbeds. and swimming pools;
 Exercise and training devices, whirlpools, portable whirlpool pumps, sauna baths, or massage devices;
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
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Equipment or supplies to aid sleeping or sitting, including non-hospital electric and air beds, water beds, pillows,
sheets, blankets, warming or cooling devices, bed tables and reclining chairs;
Equipment installed in your home, workplace or other environment, including stair-glides, elevators,
wheelchair ramps, or equipment to alter air quality, humidity or temperature;
Other additions or alterations to your home, workplace or other environment, including room additions,
changes in cabinets, countertops, doorways, lighting, wiring, furniture, communication aids, wireless alert
systems, or home monitoring;
Services and supplies furnished mainly to provide a surrounding free from exposure that can worsen your
illness or injury;
Removal from your home, worksite or other environment of carpeting, hypo-allergenic pillows, mattresses,
paint, mold, asbestos, fiberglass, dust, pet dander, pests or other potential sources of allergies or illness; and
Transportation devices, including stair-climbing wheelchairs, personal transporters, bicycles, automobiles,
vans or trucks, or alterations to any vehicle or transportation device.
Home births: Any services and supplies related to births occurring in the home or in a place not licensed to perform
deliveries.
Infertility: except as specifically described in the What the Plan Covers Section, any services, treatments,
procedures or supplies that are designed to enhance fertility or the likelihood of conception, including but not
limited to:
 Injectable infertility medications, including but not limited to menotropins, hCG, GnRH agonists, and IVIG;
 Infertility services for couples in which 1 of the partners has had a previous sterilization procedure, with or
without surgical reversal;
 Procedures, services and supplies to reverse voluntary sterilization;
charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers or
surrogacy; donor egg retrieval or fees associated with donor egg programs, including but not limited to fees for
laboratory tests;
ultrasounds, laboratory tests, etc.); any charges associated with a frozen embryo or egg transfer, including but
not limited to thawing charges;
 Home ovulation prediction kits or home pregnancy tests; and
Maintenance Care.
Medicare: Payment for that portion of the charge for which Medicare or another party is the primary payer.
Miscellaneous charges for services or supplies including:
 Annual or other charges to be in a physician’s practice;
 Charges to have preferred access to a physician’s services such as boutique or concierge physician practices;
 Cancelled or missed appointment charges or charges to complete claim forms;
 Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient did not
have coverage (to the extent exclusion is permitted by law) including:
 Care in charitable institutions;
 Care for conditions related to current or previous military service;
 Care while in the custody of a governmental authority;
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

Any care a public hospital or other facility is required to provide; or
Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity,
except to the extent coverage is required by applicable laws.
Nursing and home health aide services provided outside of the home (such as in conjunction with school,
vacation, work or recreational activities).
Non-medically necessary services, including but not limited to, those treatments, services, prescription drugs and
supplies which are not medically necessary, as determined by Aetna, for the diagnosis and treatment of illness,
injury, restoration of physiological functions, or covered preventive services. This applies even if they are
prescribed, recommended or approved by your physician or dentist.
Personal comfort and convenience items: Any service or supply primarily for your convenience and personal
comfort or that of a third party, including: Telephone, television, internet, barber or beauty service or other guest
services; housekeeping, cooking, cleaning, shopping, monitoring, security or other home services; and travel,
transportation, or living expenses, rest cures, recreational or diversional therapy.
Private duty nursing during your stay in a hospital, and outpatient private duty nursing services, except as
specifically described in the Private Duty Nursing provision in the What the Plan Covers Section.
Sex change: Except as provided under Transgender Reassignment (Sex Change) Surgery, any treatment, drug,
service or supply related to changing sex or sexual characteristics, including:
 Surgical procedures to alter the appearance or function of the body;
 Hormones and hormone therapy;
 Prosthetic devices; and
 Medical or psychological counseling.
Services provided by a spouse, domestic partner, parent, child, step-child, brother, sister, in-law or any household
member.
Services of a resident physician or intern rendered in that capacity.
Services provided where there is no evidence of pathology, dysfunction, or disease; except as specifically provided
in connection with covered routine care and cancer screenings.
Sexual dysfunction/enhancement: Any treatment, drug, service or supply to treat sexual dysfunction, enhance
sexual performance or increase sexual desire, including:
 Surgery, drugs, implants, devices or preparations to correct or enhance erectile function, enhance sensitivity, or
alter the shape or appearance of a sex organ; and
 Sex therapy, sex counseling, marriage counseling or other counseling or advisory services.
Services, including those related to pregnancy, rendered before the effective date or after the termination of
coverage, unless coverage is continued under the Continuation of Coverage section of this Benefit Description.
Services that are not covered under this Benefit Description.
Services and supplies provided in connection with treatment or care that is not covered under the plan.
Speech therapy for treatment of delays in speech development, except as specifically provided in the What the
Medical Plan Covers Section. For example, the plan does not cover therapy when it is used to improve speech skills
that have not fully developed.
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Spinal disorder, including care in connection with the detection and correction by manual or mechanical means of
structural imbalance, distortion or dislocation in the human body or other physical treatment of any condition
caused by or related to biomechanical or nerve conduction disorders of the spine including manipulation of the
spine treatment, except as specifically provided in the What the Plan Covers section.
Strength and performance: Services, devices and supplies to enhance strength, physical condition, endurance or
physical performance, including:
 Exercise equipment, memberships in health or fitness clubs, training, advice, or coaching;
 Drugs or preparations to enhance strength, performance, or endurance; and
 Treatments, services and supplies to treat illnesses, injuries or disabilities related to the use of
performance-enhancing drugs or preparations.
defects amenable to surgical repair (such as cleft lip/palate), are not covered (except as provided for the treatment of
Autism Spectrum Disorders). Examples of non-covered diagnoses include Pervasive Developmental Disorders,
Down Syndrome, and Cerebral Palsy, as they are considered both developmental and/or chronic in nature.
Therapies and tests: Any of the following treatments or procedures:
 Aromatherapy;
 Bio-feedback and bioenergetic therapy;
 Carbon dioxide therapy;
 Chelation therapy (except for heavy metal poisoning);
 Computer-aided tomography (CAT) scanning of the entire body;
 Educational therapy, except as provided for the treatment of Autism Spectrum Disorder;
 Gastric irrigation;
 Hair analysis;
 Hyperbaric therapy, except for the treatment of decompression or to promote healing of wounds;
 Hypnosis, and hypnotherapy, except when performed by a physician as a form of anesthesia in connection with
covered surgery;
 Lovaas therapy;
 Massage therapy;
 Megavitamin therapy;
 Primal therapy;
 Psychodrama;
 Purging;
 Recreational therapy;
 Rolfing;
 Sensory or auditory integration therapy;
 Sleep therapy;
 Thermograms and thermography.
Tobacco Use: Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products
or to treat or reduce nicotine addiction, dependence or cravings, including counseling, hypnosis and other therapies,
medications, nicotine patches and gum except as specifically provided in the What the Plan Covers section.
Transplant-The transplant coverage does not include charges for:
 Services and supplies furnished to a donor when recipient is not a covered person;
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
Harvesting and/or storage of organs, without the expectation of immediate transplantation for an existing
illness;
Harvesting and/or storage of bone marrow, tissue or stem cells without the expectation of transplantation within
12 months for an existing illness;
Cornea (corneal graft with amniotic membrane) or cartilage (autologous chondrocyte or autologous
osteochondral mosaicplasty) transplants, unless otherwise precertified by Aetna.
Transportation costs, including ambulance services for routine transportation to receive outpatient or inpatient
services except as described in the What the Plan Covers section.
Unauthorized services, including any service obtained by or on behalf of a covered person without Precertification
by Aetna when required. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation.
Vision-related services and supplies, except as described in the What the Plan Covers section. The plan does not
cover:
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Special supplies such as non-prescription sunglasses and subnormal vision aids;
Vision service or supply which does not meet professionally accepted standards;
Eye exams during your stay in a hospital or other facility for health care;
Eye exams for contact lenses or their fitting;
Eyeglasses or duplicate or spare eyeglasses or lenses or frames;
Replacement of lenses or frames that are lost or stolen or broken;
Acuity tests;
Eye surgery for the correction of vision, including radial keratotomy, LASIK and similar procedures;
Services to treat errors of refraction.
Weight: Any treatment, drug service or supply intended to decrease or increase body weight, control weight or treat
obesity, including morbid obesity, regardless of the existence of comorbid conditions; except as specifically
provided in the What the Plan Covers section, including but not limited to:

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
Liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery; surgical procedures
medical treatments, weight control/loss programs and other services and supplies that are primarily intended to
treat, or are related to the treatment of obesity, including morbid obesity;
Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food or food
supplements, appetite suppressants and other medications;
Counseling, coaching, training, hypnosis or other forms of therapy; and
Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or other
forms of activity or activity enhancement.
Work related: Any illness or injury related to employment or self-employment including any illness or injury that
arises out of (or in the course of) any work for pay or profit, unless no other source of coverage or reimbursement is
available to you for the services or supplies. Sources of coverage or reimbursement may include your employer,
workers’ compensation, or an occupational illness or similar program under local, state or federal law. A source of
coverage or reimbursement will be considered available to you even if you waived your right to payment from that
source. If you are also covered under a workers’ compensation law or similar law, and submit proof that you are not
covered for a particular illness or injury under such law, that illness or injury will be considered
“non-occupational” regardless of cause.
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When Coverage Ends
Coverage under your plan can end for a variety of reasons. In this section, you will find details on how and why
coverage ends, and how you may still be able to continue coverage.
When Coverage Ends for Employees
Your Aetna health benefits coverage will end if:
 The Aetna health benefits plan is discontinued;
 You voluntarily stop your coverage;
 You are no longer eligible for coverage;
 You do not make any required contributions;
 You become covered under another plan offered by your employer;
 You have exhausted your overall maximum lifetime benefit under your health plan, if your plan contains such a
maximum benefit; or
 Your employer notifies Aetna that your employment is ended.
It is your employer’s responsibility to let Aetna know when your employment ends.
Your Proof of Prior Medical Coverage
Under the Health Insurance Portability and Accountability Act of 1996, your employer is required to give you a
certificate of creditable coverage when your employment ends. This certificate proves that you were covered under
this plan when you were employed. Ask your employer about the certificate of creditable coverage.
When Coverage Ends for Dependents
Coverage for your dependents will end if:
 You are no longer eligible for dependents’ coverage;
 You do not make your contribution for the cost of dependents’ coverage;
 Your own coverage ends for any of the reasons listed under When Coverage Ends for Employees (This does not
apply if you use up your lifetime maximum, if included);
 Your dependent is no longer eligible for coverage. Coverage ends at the end of the calendar month when your
dependent does not meet the plan’s definition of a dependent; or
 As permitted under applicable federal and state law, your dependent becomes eligible for like benefits under
this or any other group plan offered by your employer.
In addition, a "domestic partner" will no longer be considered to be a defined dependent on the earlier to occur of:


The date this plan no longer allows coverage for domestic partners.
The date of termination of the domestic partnership. In that event, you should provide your Employer a
completed and signed Declaration of Termination of Domestic Partnership.
Coverage for dependents may continue for a period after your death. Coverage for handicapped dependents may
continue after they reach any limiting age. See Continuation of Coverage for more information.
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Continuation of Coverage
Continuing Health Care Benefits
Handicapped Dependent Children
Health Expense Coverage for your fully handicapped dependent child may be continued past the maximum age for
a dependent child. However, such coverage may not be continued if the child has been issued an individual medical
conversion policy.
Your child is fully handicapped if:
 he or she is not able to earn his or her own living because of mental retardation or a physical handicap which
started prior to the date he or she reaches the maximum age for dependent children under your plan; and
 he or she depends chiefly on you for support and maintenance.
Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date your child
reaches the maximum age under your plan.
Coverage will cease on the first to occur of:
 Cessation of the handicap.
 Failure to give proof that the handicap continues.
 Failure to have any required exam.
 Termination of Dependent Coverage as to your child for any reason other than reaching the maximum age under
your plan.
Aetna will have the right to require proof of the continuation of the handicap. Aetna also has the right to examine
your child as often as needed while the handicap continues at its own expense. An exam will not be required more
often than once each year after 2 years from the date your child reached the maximum age under your plan.
If your employer is subject to COBRA requirements, the health plan continuation is governed by the Federal
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requirements. With COBRA you and your
dependents can continue health coverage, subject to certain conditions and your payment of contributions.
Continuation rights are available following a “qualifying event” that would cause you or family members to
otherwise lose coverage. Qualifying events are listed in this section.
Continuing Coverage through COBRA
When you or your covered dependents become eligible, your employer will provide you with detailed information
on continuing your health coverage through COBRA.
You or your dependents will need to:
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

Complete and submit an application for continued health coverage, which is an election notice of your intent to
continue coverage.
Submit your application within 60 days of the qualifying event, or within 60 days of your employer’s notice of
this COBRA continuation right, if later.
Agree to pay the required contributions.
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Who Qualifies for COBRA
You have 60 days from the qualifying event to elect COBRA. If you do not submit an application within 60 days,
you will forfeit your COBRA continuation rights.
Below you will find the qualifying events and a summary of the maximum coverage periods according to COBRA
requirements.
Qualifying Event Causing Loss
of Health Coverage
Your active employment ends for
reasons other than gross
misconduct
Your working hours are reduced
You divorce or legally separate and
are no longer responsible for
dependent coverage
You become entitled to benefits
under Medicare
Your covered dependent children
no longer qualify as dependents
under the plan
You die
You are a retiree eligible for health
coverage and your former
employer files for bankruptcy
Covered Persons Eligible to
Elect Continuation
You and your dependents
Maximum Continuation Periods
Your dependents
18 months
36 months
Your dependents
36 months
Your dependent children
36 months
Your dependents
36 months
18 months
18 months
Disability May Increase Maximum Continuation to 29 Months
If You or Your Covered Dependents Are Disabled
If you or your covered dependent qualify for disability status under Title II or XVI of the Social Security Act during
the 18 month continuation period, you or your covered dependent:
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
Have the right to extend coverage beyond the initial 18 month maximum continuation period.
Qualify for an additional 11 month period, subject to the overall COBRA conditions.
Must notify your employer within 60 days of the disability determination status and before the 18 month
continuation period ends.
Must notify the employer within 30 days after the date of any final determination that you or a covered
dependent is no longer disabled.
Are responsible to pay the contributions after the 18th month, through the 29th month.
If There Are Multiple Qualifying Events
A covered dependent could qualify for an extension of the 18 or 29 month continuation period by meeting the
requirements of another qualifying event, such as divorce or death. The total continuation period, however, can
never exceed 36 months.
Determining Your Contributions For Continuation Coverage
Your contributions are regulated by law, based on the following:


For the 18 or 36 month periods, contributions may never exceed 102 percent of the plan costs.
During the 18 through 29 month period, contributions for coverage during an extended disability period may
never exceed 150 percent of the plan costs.
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When You Acquire a Dependent During a Continuation Period
If through birth, adoption or marriage, you acquire a new dependent during the continuation period, your dependent
can be added to the health plan for the remainder of the continuation period if:
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
He or she meets the definition of an eligible dependent,
Your employer is notified about your dependent within 31 days of eligibility, and
Additional contributions for continuation are paid on a timely basis.
Important Note
For more information about dependent eligibility, see the Eligibility, Enrollment and Effective Date section.
When Your COBRA Continuation Coverage Ends
Your COBRA coverage will end when the first of the following events occurs:






You or your covered dependents reach the maximum COBRA continuation period – the end of the 18, 29 or 36
months. (Coverage for a newly acquired dependent who has been added for the balance of a continuation period
would end at the same time your continuation period ends, if he or she is not disabled nor eligible for an
extended maximum).
You or your covered dependents do not pay required contributions.
You or your covered dependents become covered under another group plan that does not restrict coverage for
preexisting conditions. If your new plan limits preexisting condition coverage, the continuation coverage under
this plan may remain in effect until the preexisting clause ceases to apply or the maximum continuation period
is reached under this plan.
The date your employer no longer offers a group health plan.
The date you or a covered dependent becomes enrolled in benefits under Medicare. This does not apply if it is
contrary to the Medicare Secondary Payer Rules or other federal law.
You or your dependent dies.
Coordination of Benefits – What Happens When There is More
Than One Health Plan
Other Plans Not Including Medicare
Some persons have health coverage in addition to coverage under this Plan. Under these circumstances, it is not
intended that a plan provide duplicate benefits. For this reason, many plans, including this Plan, have a
"coordination of benefits" provision.
Under the coordination of benefits provision of this Plan, the amount normally reimbursed under this Plan is
reduced to take into account payments made by "other plans".
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When this and another health expenses coverage plan applies, the order in which the various plans will pay benefits
must be figured. This will be done as follows using the first rule that applies:
1. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a plan which
contains such rules.
2. A plan which covers a person other than as a dependent will be deemed to pay its benefits before a plan which
covers the person as a dependent; except that if the person is also a Medicare beneficiary and as a result of the
Social Security Act of 1965, as amended, Medicare is:
 secondary to the plan covering the person as a dependent; and
 primary to the plan covering the person as other than a dependent;
The benefits of a plan which covers the person as a dependent will be determined before the benefits of a plan
which:
 covers the person as other than a dependent; and
 is secondary to Medicare.
3. Except in the case of a dependent child whose parents are divorced or separated; the plan which covers the
person as a dependent of a person whose birthday comes first in a calendar year will be primary to the plan
which covers the person as a dependent of a person whose birthday comes later in that calendar year. If both
parents have the same birthday, the benefits of a plan which covered one parent longer are determined before
those of a plan which covered the other parent for a shorter period of time.
If the other plan does not have the rule described in this provision (3) but instead has a rule based on the gender
of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will
determine the order of benefits.
4. In the case of a dependent child whose parents are divorced or separated:
a. If there is a court decree which states that the parents shall share joint custody of a dependent child, without
stating that one of the parents is responsible for the health care expenses of the child, the order of benefit
determination rules specified in (3) above will apply.
b. If there is a court decree which makes one parent financially responsible for the medical, dental or other
health care expenses of such child, the benefits of a plan which covers the child as a dependent of such
parent will be determined before the benefits of any other plan which covers the child as a dependent child.
c. If there is not such a court decree:

If the parent with custody of the child has not remarried, the benefits of a plan which covers the child as
a dependent of the parent with custody of the child will be determined before the benefits of a plan
which covers the child as a dependent of the parent without custody.
 If the parent with custody of the child has remarried, the benefits of a plan which covers the child as a
dependent of the parent with custody shall be determined before the benefits of a plan which covers that
child as a dependent of the stepparent. The benefits of a plan which covers that child as a dependent of
the stepparent will be determined before the benefits of a plan which covers that child as a dependent of
the parent without custody.
5. If 1, 2, 3 and 4 above do not establish an order of payment, the plan under which the person has been covered for
the longest will be deemed to pay its benefits first; except that:
The benefits of a plan which covers the person on whose expenses claim is based as a:
 laid-off or retired employee; or
 the dependent of such person.
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Shall be determined after the benefits of any other plan which covers such person as:
 an employee who is not laid-off or retired; or
 dependent of such person.
If the other plan does not have a provision:
 regarding laid-off or retired employees; and
 as a result, each plan determines its benefits after the other;
then the above paragraph will not apply.
The benefits of a plan which covers the person on whose expenses claim is based under a right of continuation
pursuant to federal or state law shall be determined after the benefits of any other plan which covers the person
other than under such right of continuation.
 regarding right of continuation pursuant to federal or state law; and
The general rule is that the benefits otherwise payable under this Plan for all expenses processed during a single
"processed claim transaction" will be reduced by the total benefits payable under all "other plans" for the same
expenses. An exception to this rule is that when the coordination of benefits rules of this Plan and any "other plan"
both agree that this Plan is primary, the benefits of the other plan will be ignored in applying this rule. As used in
this paragraph, a "processed claim transaction" is a group of actual or prospective charges submitted to Aetna for
consideration, that have been grouped together for administrative purposes as a "claim transaction" in accordance
with Aetna's then current rules. If the contract includes both medical and dental coverage, those coverages will be
considered separate plans. The Medical/Pharmacy coverage will be coordinated with other Medical/Pharmacy plans.
In turn, the dental coverage will be coordinated with other dental plans.
In order to administer this provision, Aetna can release or obtain data. Aetna can also make or recover payments.
Other Plan
This means any other plan of health expense coverage under:



Group insurance.
Any other type of coverage for persons in a group. This includes plans that are insured and those that are not.
No-fault auto insurance required by law and provided on other than a group basis. Only the level of benefits
required by the law will be counted.
When you have Medicare Coverage
Effect of Medicare
Health Expense Coverage will be changed for any person while eligible for Medicare.
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A person is "eligible for Medicare" if he or she:


is covered under it;
is not covered under it because of:
 having refused it;
 having dropped it;
 having failed to make proper request for it.
These are the changes:




All health expenses covered under this Plan will be reduced by any Medicare benefits available for those
expenses. This will be done before the health benefits of this Plan are figured.
Charges used to satisfy a person's Part B deductible under Medicare will be applied under this Plan in the order
received by Aetna. Two or more charges received at the same time will be applied starting with the largest first.
Medicare benefits will be taken into account for any person while he or she is eligible for Medicare. This will be
done whether or not he or she is entitled to Medicare benefits.
Any rule for coordinating "other plan" benefits with those under this Plan will be applied after this Plan's
benefits have been figured under the above rules. Allowable Expenses will be reduced by any Medicare benefits
available for those expenses.
Coverage will not be changed at any time when your Employer's compliance with federal law requires this Plan's
benefits for a person to be figured before benefits are figured under Medicare.
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General Provisions
Type of Coverage
Coverage under the plan is non-occupational. Only non-occupational accidental injuries and non-occupational
illnesses are covered. The plan covers charges made for services and supplies only while the person is covered
under the plan.
Physical Examinations
Aetna will have the right and opportunity to examine and evaluate any person who is the basis of any claim at all
reasonable times while a claim is pending or under review. This will be done at no cost to you.
Legal Action
No legal action can be brought to recover payment under any benefit after 3 years from the deadline for filing
claims.
Additional Provisions
The following additional provisions apply to your coverage:
 This Benefit Description applies to coverage only, and does not restrict your ability to receive health care
services that are not, or might not be, covered.
 You cannot receive multiple coverage under the plan because you are connected with more than one employer.
 In the event of a misstatement of any fact affecting your coverage under the plan, the true facts will be used to
determine the coverage in force.
 This document describes the main features of the plan. If you have any questions about the terms of the plan or
about the proper payment of benefits, contact your employer or Aetna.
 The plan may be changed or discontinued with respect to your coverage.
Assignments
Coverage and your rights under this plan may not be assigned. A direction to pay a provider is not an assignment of
any right under this plan or of any legal or equitable right to institute any court proceeding.
Misstatements
Aetna’s failure to implement or insist upon compliance with any provision of this plan at any given time or times,
shall not constitute a waiver of Aetna’s right to implement or insist upon compliance with that provision at any
other time or times.
Fraudulent misstatements in connection with any claim or application for coverage may result in termination of all
coverage under this plan.
Rescission of Coverage
Aetna may rescind your coverage if you, or the person seeking coverage on your behalf:

Performs an act, practice or omission that constitutes fraud; or
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
Makes an intentional misrepresentation of material fact.
You will be given 30 days advance written notice of any rescission of coverage.
As to medical and prescription drug coverage only, you have the right to an internal Appeal with Aetna and/or the
right to a third party review conducted by an independent External Review Organization if your coverage under this
Benefit Description is rescinded retroactive to its Effective Date.
Subrogation and Right of Recovery Provision
The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or
other representative of a dependent child who incurs claims and is or has been covered by the plan. The plan's right
to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, your
decedents, minors, and incompetent or disabled persons. "You" or "your" includes anyone on whose behalf the plan
pays benefits. No adult covered person hereunder may assign any rights that it may have to recover medical
expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person
without the prior express written consent of the plan.
The plan's right of subrogation or reimbursement, as set forth below, extend to all insurance coverage available to
you due to an injury, illness or condition for which the plan has paid medical claims (including, but not limited to,
liability coverage, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage,
medical payments coverage, workers' compensation coverage, no-fault automobile coverage or any first party
insurance coverage).
Your health plan is always secondary to automobile no-fault coverage, personal injury protection coverage, or
medical payments coverage.
Subrogation
The right of subrogation means the plan is entitled to pursue any claims that you may have in order to recover the
benefits paid by the plan. Immediately upon paying or providing any benefit under the plan, the plan shall be
subrogated to (stand in the place of) all rights of recovery with respect to any claim or potential claim against any
party, due to an injury, illness or condition to the full extent of benefits provided or to be provided by the plan. The
plan may assert a claim or file suit in your name and take appropriate action to assert its subrogation claim, with or
without your consent. The plan is not required to pay you part of any recovery it may obtain, even if it files suit in
your name.
Reimbursement
If you receive any payment as a result of an injury, illness or condition, you agree to reimburse the plan first from
such payment for all amounts the plan has paid and will pay as a result of that injury, illness or condition, up to and
including the full amount of your recovery.
Constructive Trust
By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any provider)
you agree that if you receive any payment as a result of an injury, illness or condition, you will serve as a
constructive trustee over those funds. Failure to hold such funds in trust will be deemed a breach of your fiduciary
duty to the plan.
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Lien Rights
Further, the plan will automatically have a lien to the extent of benefits paid by the plan for the treatment of the
illness, injury or condition upon any recovery whether by settlement, judgment, or otherwise, related to treatment
for any illness, injury or condition for which the plan paid benefits. The lien may be enforced against any party who
possesses funds or proceeds representing the amount of benefits paid by the plan including, but not limited to, you,
your representative or agent, and/or any other source possessing funds representing the amount of benefits paid by
the plan.
Assignment
In order to secure the plan's recovery rights, you agree to assign to the plan any benefits or claims or rights of
recovery you have under any automobile policy or other coverage, to the full extent of the plan's subrogation and
reimbursement claims. This assignment allows the plan to pursue any claim you may have, whether or not you
choose to pursue the claim.
First-Priority Claim
By accepting benefits from the plan, you acknowledge that the plan’s recovery rights are a first priority claim and
are to be repaid to the plan before you receive any recovery for your damages. The plan shall be entitled to full
reimbursement on a first-dollar basis from any payments, even if such payment to the plan will result in a recovery
which is insufficient to make you whole or to compensate you in part or in whole for the damages sustained. The
plan is not required to participate in or pay your court costs or attorney fees to any attorney you hire to pursue your
damage claim.
Applicability to All Settlements and Judgments
The terms of this entire subrogation and right of recovery provision shall apply and the plan is entitled to full
recovery regardless of whether any liability for payment is admitted and regardless of whether the settlement or
judgment identifies the medical benefits the plan provided or purports to allocate any portion of such settlement or
judgment to payment of expenses other than medical expenses. The plan is entitled to recover from any and all
settlements or judgments, even those designated as pain and suffering, non-economic damages, and/or general
damages only. The plan's claim will not be reduced due to your own negligence.
Cooperation
You agree to cooperate fully with the plan’s efforts to recover benefits paid. It is your duty to notify the plan within
30 days of the date when any notice is given to any party, including an insurance company or attorney, of your
intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or
condition. You and your agents shall provide all information requested by the plan, the Claims Administrator or its
representative including, but not limited to, completing and submitting any applications or other forms or
statements as the plan may reasonably request and all documents related to or filed in person injury litigation.
Failure to provide this information, failure to assist the plan in pursuit of its subrogation rights, or failure to
reimburse the plan from any settlement or recovery you receive may result in the termination of your health benefits
or the institution of court proceedings against you.
You shall do nothing to prejudice the plan’s subrogation or recovery interest or to prejudice the plan’s ability to
enforce the terms of this plan provision. This includes, but is not limited to, refraining from making any settlement
or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan. If you fail to
cooperate with the plan in its efforts to recover such amounts or do anything to hinder or prevent such a recovery,
you will cease to be entitled to any further plan benefits. The plan will also have the right to withhold or offset future
benefit payments up to the amount of any settlement, judgment, or recovery you obtain, regardless of whether the
settlement, judgment or recovery is designated to cover future medical benefits or expenses.
You acknowledge that the plan has the right to conduct an investigation regarding the injury, illness or condition to
identify potential sources of recovery. The plan reserves the right to notify all parties and his/ her agents of its lien.
Agents include, but are not limited to, insurance companies and attorneys.
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You acknowledge that the plan has notified you that it has the right pursuant to the Health Insurance Portability &
Accountability Act ("HIPAA"), 42 U.S.C. Section 1301 et seq, to share your personal health information in
exercising its subrogation and reimbursement rights.
Interpretation
In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or
questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the plan shall have
the sole authority and discretion to resolve all disputes regarding the interpretation of this provision.
Jurisdiction
By accepting benefits from the plan, you agree that any court proceeding with respect to this provision may be
brought in any court of competent jurisdiction as the plan may elect. By accepting such benefits, you hereby submit
to each such jurisdiction, waiving whatever rights may correspond by reason of your present or future domicile. By
accepting such benefits, you also agree to pay all attorneys' fees the plan incurs in successful attempts to recover
amounts the plan is entitled to under this section.
Workers’ Compensation
If benefits are paid under the Aetna medical benefits plan and Aetna determines you received Workers'
Compensation benefits for the same incident, Aetna has the right to recover as described under the Subrogation and
Right of Reimbursement provision. Aetna, on behalf of the Plan, will exercise its right to recover against you.
The Recovery Rights will be applied even though:




The Workers' Compensation benefits are in dispute or are made by means of settlement or compromise;
No final determination is made that bodily injury or illness was sustained in the course of or resulted from your
employment;
The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by you or the
Workers' Compensation carrier; or
The medical or health care benefits are specifically excluded from the Workers' Compensation settlement or
compromise.
You hereby agree that, in consideration for the coverage provided by this Aetna medical benefits plan, you will
notify Aetna of any Workers' Compensation claim you make, and that you agree to reimburse Aetna, on behalf of
the Plan, as described above.
If benefits are paid under this Aetna medical benefits plan, and you or your covered dependent recover from a
responsible party by settlement, judgment or otherwise, Aetna, on behalf of the Plan, has a right to recover from you
or your covered dependent an amount equal to the amount the Plan paid.
Recovery of Overpayments
Health Coverage
If a benefit payment is made by the Plan, to or on your behalf, which exceeds the benefit amount that you are
entitled to receive, the Plan has the right:


To require the return of the overpayment; or
To reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that person or
another person in his or her family.
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Such right does not affect any other right of recovery the Plan may have with respect to such overpayment.
Reporting of Claims
A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss. Your
employer has claim forms.
All claims should be reported promptly. The deadline for filing a claim is 90 days after the date of the loss.
If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still be
accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health benefits will not
be covered if they are filed more than 2 years after the deadline.
Payment of Benefits
Benefits will be paid as soon as the necessary proof to support the claim is received. Written proof must be provided
for all benefits.
All covered health benefits are payable to you. However, Aetna has the right to pay any health benefits to the
service provider. This will be done unless you have told Aetna otherwise by the time you file the claim.
The Plan may pay up to $1,000 of any other benefit to any of your relatives whom it believes fairly entitled to it.
This can be done if the benefit is payable to you and you are a minor or not able to give a valid release.
When a PCP provides care for you or a covered dependent, or care is provided by a network provider (network
services or supplies), the network provider will take care of filing claims. However, when you seek care on your
own (out-of-network services and supplies), you are responsible for filing your own claims.
Records of Expenses
Keep complete records of the expenses of each person. They will be required when a claim is made.
Very important are:



Names of physicians, dentists and others who furnish services.
Dates expenses are incurred.
Copies of all bills and receipts.
Contacting Aetna
If you have questions, comments or concerns about your benefits or coverage, or if you are required to submit
information to Aetna, you may contact Aetna’s Home Office at:
Aetna Life Insurance Company
Hartford, CT 06156
You may also use Aetna’s toll free Member Services phone number on your ID card or visit Aetna’s web site at
www.aetna.com.
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Discount Programs
Discount Arrangements
From time to time, we may offer, provide, or arrange for discount arrangements or special rates from certain service
providers such as pharmacies, optometrists, dentists, alternative medicine, wellness and healthy living providers to
you under this plan. Some of these arrangements may be made available through third parties who may make
payments to Aetna in exchange for making these services available.
The third party service providers are independent contractors and are solely responsible to you for the provision of
any such goods and/or services. We reserve the right to modify or discontinue such arrangements at any time. These
discount arrangements are not insurance. There are no benefits payable to you nor do we compensate providers for
services they may render through discount arrangements.
Incentives
In order to encourage you to access certain medical services when deemed appropriate by you in consultation with
your physician or other service providers, we may, from time to time, offer to waive or reduce a member’s
copayment, payment percentage, and/or a deductible otherwise required under the plan or offer coupons or other
financial incentives. We have the right to determine the amount and duration of any waiver, reduction, coupon, or
financial incentive and to limit the covered persons to whom these arrangements are available.
Claims, Appeals and External Review
Filing Health Claims under the Plan
Under the Plan, you may file claims for Plan benefits and appeal adverse claim determinations. Any reference to
“you” in this Claims, Appeals and External Review section includes you and your Authorized Representative. An
"Authorized Representative" is a person you authorize, in writing, to act on your behalf. The Plan will also
recognize a court order giving a person authority to submit claims on your behalf. In the case of an urgent care claim,
a health care professional with knowledge of your condition may always act as your Authorized Representative.
If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna Life Insurance
Company (Aetna). The notice will explain the reason for the denial and the appeal procedures available under the
Plan.
Urgent Care Claims
An “Urgent Care Claim” is any claim for medical care or treatment for which the application of the time periods for
making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain
maximum function, or, in the opinion of a physician with knowledge of your medical condition, would subject you
to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
If the Plan requires advance approval of a service, supply or procedure before a benefit will be payable, and if Aetna
or your physician determines that it is an Urgent Care Claim, you will be notified of the decision, whether adverse or
not, as soon as possible but not later than 72 hours after the claim is received.
If there is not sufficient information to decide the claim, you will be notified of the information necessary to
complete the claim as soon as possible, but not later than 24 hours after receipt of the claim. You will be given a
reasonable additional amount of time, but not less than 48 hours, to provide the information, and you will be notified
of the decision not later than 48 hours after the end of that additional time period (or after receipt of the information,
if earlier).
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Other Claims (Pre-Service and Post-Service)
If the Plan requires you to obtain advance approval of a non-urgent service, supply or procedure before a benefit
will be payable, a request for advance approval is considered a pre-service claim. You will be notified of the
decision not later than 15 days after receipt of the pre-service claim.
For other claims (post-service claims), you will be notified of the decision not later than 30 days after receipt of the
claim.
For either a pre-service or a post-service claim, these time periods may be extended up to an additional 15 days due
to circumstances outside Aetna’s control. In that case, you will be notified of the extension before the end of the
initial 15 or 30-day period. For example, they may be extended because you have not submitted sufficient
information, in which case you will be notified of the specific information necessary and given an additional period
of at least 45 days after receiving the notice to furnish that information. You will be notified of Aetna’s claim
decision no later than 15 days after the end of that additional period (or after receipt of the information, if earlier).
For pre-service claims which name a specific claimant, medical condition, and service or supply for which approval
is requested, and which are submitted to an Aetna representative responsible for handling benefit matters, but which
otherwise fail to follow the Plan's procedures for filing pre-service claims, you will be notified of the failure within
5 days (within 24 hours in the case of an urgent care claim) and of the proper procedures to be followed. The notice
may be oral unless you request written notification.
Ongoing Course of Treatment
If you have received pre-authorization for an ongoing course of treatment, you will be notified in advance if the
previously authorized course of treatment is intended to be terminated or reduced so that you will have an
opportunity to appeal any decision to Aetna and receive a decision on that appeal before the termination or
reduction takes effect. If the course of treatment involves urgent care, and you request an extension of the course of
treatment at least 24 hours before its expiration, you will be notified of the decision within 24 hours after receipt of
the request.
Health Claims – Standard Appeals
As an individual enrolled in the Plan, you have the right to file an appeal from an Adverse Benefit Determination
relating to service(s) you have received or could have received from your health care provider under the Plan.
An “Adverse Benefit Determination” is defined as a denial, reduction, termination of, or failure to, provide or make
payment (in whole or in part) for a service, supply or benefit. Such Adverse Benefit Determination may be based on:





Your eligibility for coverage, including a retrospective termination of coverage (whether or not there is an
adverse effect on any particular benefit);
Coverage determinations, including plan limitations or exclusions;
The results of any Utilization Review activities;
A decision that the service or supply is experimental or investigational; or
A decision that the service or supply is not medically necessary.
A “Final Internal Adverse Benefit Determination” is defined as an Adverse Benefit Determination that has been
upheld by the appropriate named fiduciary (Aetna) at the completion of the internal appeals process, or an Adverse
Benefit Determination for which the internal appeals process has been exhausted.
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Exhaustion of Internal Appeals Process
Generally, you are required to complete all appeal processes of the Plan before being able to obtain External Review
or bring an action in litigation. However, if Aetna, or the Plan or its designee, does not strictly adhere to all claim
determination and appeal requirements under applicable federal law, you are considered to have exhausted the
Plan’s appeal requirements (“Deemed Exhaustion”) and may proceed with External Review or may pursue any
available remedies under §502(a) of ERISA or under state law, as applicable.
There is an exception to the Deemed Exhaustion rule. Your claim or internal appeal may not go straight to External
Review if:
A rule violation was minor and is not likely to influence a decision or harm you; and
It was for a good cause or was beyond Aetna’s or the Plan’s or its designee’s control; and
It was part of an ongoing good faith exchange between you and Aetna or the Plan.
This exception is not available if the rule violation is part of a pattern or practice of violations by Aetna or the Plan.
You may request a written explanation of the violation from the Plan or Aetna, and the Plan or Aetna must provide
such explanation within 10 days, including a specific description of its bases, if any, for asserting that the violation
should not cause the internal claims and appeals process to be deemed exhausted. If an External Reviewer or a court
rejects your request for immediate review on the basis that the plan met the standards for the exception, you have
the right to resubmit and pursue the internal appeal of the claim. In such a case, within a reasonable time after the
External Reviewer or court rejects the claim for immediate review (not to exceed 10 days), you will receive notice
of the opportunity to resubmit and pursue the internal appeal of the claim. Time periods for re-filing the claim shall
begin to run upon your receipt of such notice.
Full and Fair Review of Claim Determinations and Appeals
Aetna will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by
Aetna (or at the direction of Aetna), or any new or additional rationale as soon as possible and sufficiently in
advance of the date on which the notice of Final Internal Adverse Benefit Determination is provided, to give you a
reasonable opportunity to respond prior to that date.
You may file an appeal in writing to Aetna at the address provided in this Benefit Description, or, if your appeal is of
an urgent nature, you may call Aetna’s Member Services Unit at the toll-free phone number on your ID card. Your
request should include the group name (that is, your employer), your name, member ID, or other identifying
information shown on the front of the Explanation of Benefits form, and any other comments, documents, records
and other information you would like to have considered, whether or not submitted in connection with the initial
claim.
An Aetna representative may call you or your health care provider to obtain medical records and/or other pertinent
information in order to respond to your appeal.
You will have 180 days following receipt of an Adverse Benefit Determination to appeal the determination to Aetna.
You will be notified of the decision not later than 15 days (for pre-service claims) or 30 days (for post-service
claims) after the appeal is received. You may submit written comments, documents, records and other information
relating to your claim, whether or not the comments, documents, records or other information were submitted in
connection with the initial claim. A copy of the specific rule, guideline or protocol relied upon in the Adverse
Benefit Determination will be provided free of charge upon request by you or your Authorized Representative. You
may also request that Aetna provide you, free of charge, copies of all documents, records and other information
relevant to the claim.
If your claim involves urgent care, an expedited appeal may be initiated by a telephone call to the phone number
included in your denial, or to Aetna's Member Services. Aetna's Member Services telephone number is on your
Identification Card. You or your Authorized Representative may appeal urgent care claim denials either orally or in
writing. All necessary information, including the appeal decision, will be communicated between you or your
136
Authorized Representative and Aetna by telephone, facsimile, or other similar method. You will be notified of the
decision not later than 36 hours after the appeal is received.
If you are dissatisfied with the appeal decision on an urgent care claim, you may file a second level appeal with
Aetna. You will be notified of the decision not later than 36 hours after the appeal is received.
If you are dissatisfied with a pre-service or post-service appeal decision, you may file a second level appeal with
Aetna within 60 days of receipt of the level one appeal decision. Aetna will notify you of the decision not later than
15 days (for pre-service claims) or 30 days (for post-service claims) after the appeal is received.
If you do not agree with the Final Internal Adverse Benefit Determination on review, you have the right to bring a
civil action under Section 502(a) of ERISA, if applicable.
Health Claims – Voluntary Appeals
External Review
“External Review” is a review of an eligible Adverse Benefit Determination or a Final Internal Adverse Benefit
Determination by an Independent Review Organization/External Review Organization (ERO) or by the State
Insurance Commissioner, if applicable.
A “Final External Review Decision” is a determination by an ERO at the conclusion of an External Review.
You must complete all of the levels of standard appeal described above before you can request External Review,
other than in a case of Deemed Exhaustion. Subject to verification procedures that the Plan may establish, your
Authorized Representative may act on your behalf in filing and pursuing this voluntary appeal.
You may file a voluntary appeal for External Review of any Adverse Benefit Determination or any Final Internal
Adverse Benefit Determination that qualifies as set forth below.
The notice of Adverse Benefit Determination or Final Internal Adverse Benefit Determination that you receive from
Aetna will describe the process to follow if you wish to pursue an External Review, and will include a copy of the
Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 123 calendar days of the date you received
the Adverse Benefit Determination or Final Internal Adverse Benefit Determination notice. If the last filing date
would fall on a Saturday, Sunday or Federal holiday, the last filing date is extended to the next day that is not a
Saturday, Sunday or Federal holiday. You also must include a copy of the notice and all other pertinent information
that supports your request.
If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The
filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is
voluntary and you are not required to undertake it before pursuing legal action.
If you choose not to file for voluntary review, the Plan will not assert that you have failed to exhaust your
administrative remedies because of that choice.
137
Request for External Review
The External Review process under this Plan gives you the opportunity to receive review of an Adverse Benefit
Determination (including a Final Internal Adverse Benefit Determination) conducted pursuant to applicable law.
Your request will be eligible for External Review if the claim decision involves medical judgment and the following
are satisfied:



Aetna, or the Plan or its designee, does not strictly adhere to all claim determination and appeal requirements
under federal law (except for minor violations); or
the standard levels of appeal have been exhausted; or
the appeal relates to a rescission, defined as a cancellation or discontinuance of coverage which has retroactive
effect.
An Adverse Benefit Determination based upon your eligibility is not eligible for External Review.
If upon the final standard level of appeal, the coverage denial is upheld and it is determined that you are eligible for
External Review, you will be informed in writing of the steps necessary to request an External Review.
An independent review organization refers the case for review by a neutral, independent clinical reviewer with
appropriate expertise in the area in question. The decision of the independent external expert reviewer is binding on
you, Aetna and the Plan unless otherwise allowed by law.
Preliminary Review
Within 5 business days following the date of receipt of the request, Aetna must provide a preliminary review
determining: you were covered under the Plan at the time the service was requested or provided, the determination
does not relate to eligibility, you have exhausted the internal appeals process (unless Deemed Exhaustion applies),
and you have provided all paperwork necessary to complete the External Review and you are eligible for external
review.
Within one business day after completion of the preliminary review, Aetna must issue to you a notification in
writing. If the request is complete but not eligible for External Review, such notification will include the reasons for
its ineligibility and contact information for the Employee Benefits Security Administration (toll-free number
866-444-EBSA (3272)). If the request is not complete, such notification will describe the information or materials
needed to make the request complete and Aetna must allow you to perfect the request for External Review within
the 123 calendar days filing period or within the 48 hour period following the receipt of the notification, whichever
is later.
Referral to ERO
Aetna will assign an ERO accredited as required under federal law, to conduct the External Review. The assigned
ERO will timely notify you in writing of the request’s eligibility and acceptance for External Review, and will
provide an opportunity for you to submit in writing within 10 business days following the date of receipt, additional
information that the ERO must consider when conducting the External Review. Within one (1) business day after
making the decision, the ERO must notify you, Aetna and the Plan.
The ERO will review all of the information and documents timely received. In reaching a decision, the assigned
ERO will review the claim and not be bound by any decisions or conclusions reached during the Plan’s internal
claims and appeals process. In addition to the documents and information provided, the assigned ERO, to the extent
the information or documents are available and the ERO considers them appropriate, will consider the following in
reaching a decision:
(i) Your medical records;
(ii) The attending health care professional's recommendation;
(iii) Reports from appropriate health care professionals and other documents submitted by the Plan or issuer,
138
you, or your treating provider;
(iv) The terms of your Plan to ensure that the ERO's decision is not contrary to the terms of the Plan, unless the
terms are inconsistent with applicable law;
(v) Appropriate practice guidelines, which must include applicable evidence-based standards and may include any
other practice guidelines developed by the Federal government, national or professional medical societies,
boards, and associations;
(vi) Any applicable clinical review criteria developed and used by Aetna, unless the criteria are inconsistent with
the terms of the Plan or with applicable law; and
(vii)
The opinion of the ERO's clinical reviewer or reviewers after considering the information described in this
notice to the extent the information or documents are available and the clinical reviewer or reviewers consider
appropriate.
The assigned ERO must provide written notice of the Final External Review Decision within 45 days after the ERO
receives the request for the External Review. The ERO must deliver the notice of Final External Review Decision to
you, Aetna and the Plan.
After a Final External Review Decision, the ERO must maintain records of all claims and notices associated with
the External Review process for six years. An ERO must make such records available for examination by the
claimant, Plan, or State or Federal oversight agency upon request, except where such disclosure would violate State
or Federal privacy laws.
Upon receipt of a notice of a Final External Review Decision reversing the Adverse Benefit Determination or Final
Internal Adverse Benefit Determination, the Plan immediately must provide coverage or payment (including
immediately authorizing or immediately paying benefits) for the claim.
Expedited External Review
The Plan must allow you to request an expedited External Review at the time you receive:
(a) An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which
the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health or
would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal
appeal; or
(b) A Final Internal Adverse Benefit Determination, if you have a medical condition where the timeframe for
completion of a standard External Review would seriously jeopardize your life or health or would jeopardize
your ability to regain maximum function, or if the Final Internal Adverse Benefit Determination concerns an
admission, availability of care, continued stay, or health care item or service for which you received emergency
services, but have not been discharged from a facility.
Immediately upon receipt of the request for expedited External Review, Aetna will determine whether the request
meets the reviewability requirements set forth above for standard External Review. Aetna must immediately send
you a notice of its eligibility determination.
Referral of Expedited Review to ERO
Upon a determination that a request is eligible for External Review following preliminary review, Aetna will assign
an ERO. The ERO shall render a decision as expeditiously as your medical condition or circumstances require, but
in no event more than 72 hours after the ERO receives the request for an expedited External Review. If the notice is
not in writing, within 48 hours after the date of providing that notice, the assigned ERO must provide written
confirmation of the decision to you, Aetna and the Plan.
139
Appeal to the Plan
If you choose to appeal to the Plan or its designee following an adverse determination by External Review where
applicable or an adverse determination at the final level of standard appeals, you must do so in writing, and you
should send the following information:



The specific reason(s) for the appeal;
Copies of all past correspondence with Aetna or the ERO (including any EOBs); and
Any applicable information that you have not yet sent to Aetna and the ERO.
If you file a voluntary appeal, you will be deemed to authorize the Plan or its designee to obtain information from
Aetna relevant to your claim.
Mail your written appeal directly to:
SPE Benefits Committee
10202 W. Washington Blvd
The Plan or its designee will review your appeal. The reviewer will evaluate your claim within 60 days after you file
your appeal and make a decision. If the reviewer needs more time, the reviewer may take an additional 60-day
period. The reviewer will notify you in advance of this extension. The reviewer will follow relevant internal rules
maintained by Aetna to the extent they do not conflict with the Plan’s own internal guidelines.
The reviewer will notify you of the final decision on your appeal electronically or in writing. The written notice will
give you the reason for the decision and what Plan provisions apply.
All decisions by the Plan or its designee with respect to your claim shall be final and binding.
AETNA SELECT EPO MEDICAL PLAN
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Per Admission
Copayment/Deductible
$100 per admission
Not applicable
Plan Maximum Out of Pocket Limit includes plan deductible and copayments.
 For network expenses: $2,000
 For network expenses: $5,000
140
person
Unlimited
Not applicable
Below.
PLAN FEATURES
Preventive Care
Office Visits -
NETWORK
OUT OF NETWORK
100% per visit.
Not Covered
Covered Persons through age 21:
Maximum Age & Visit Limits per
Calendar Year
Administration.
Not Covered
For details, contact your physician
Covered Persons ages 22 but less
1 visit
than 65:
Maximum Visits per Calendar Year
Not Covered
Covered Persons age 65 and over: 1 visit
Maximum Visits per Calendar Year
Not Covered.
physician's office
100% per visit.
Not Covered
Screening & Counseling
Services-Obesity, Misuse of
Alcohol and/or Drugs & Use of
Tobacco Products
100% per visit.
Not Covered
141
Obesity
chronic disease)*
Not Covered.
Not Covered.
Not Covered.
Office Visits
100%
Not Covered
applies
Maximum Visits
per Calendar Year
1 visit
Not Covered
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Other
100% per visit
Not Covered
applies.
142
Maximums
Administration.
Not Covered
Prenatal Care
Office Visits
100% per visit
Not Covered
100% per visit
Not Covered.
Not Covered
100% per item
Not Covered
Outpatient
100% per visit
Not Covered.
No deductible applies.
Outpatient
100% per visit
Not Covered.
No deductible applies.
143
100% per visit
Not Covered.
applies.
Contraceptive Counseling Services 2* visits per 12 months
Not Covered.
100% per visit
Inpatient
Not Covered
Outpatient
100% per visit
Not Covered
PLAN FEATURES
Physician Services
Physician
non-specialist
NETWORK
OUT-OF-NETWORK
100%
Not Covered
applies.
100%
Not Covered
applies.
100%
applies.
144
Not Covered
100%
Not Covered
applies.
Immunizations
100% per visit
Not Covered
Use
100% per visit
Not Covered
Use
Refer to the Preventive Care Benefit Not Applicable
section earlier in this Schedule of
Benefits for maximums that may
apply to these types of services
100% per visit
Not Covered
Refer to the Preventive Care Benefit Not Applicable
section earlier in this Schedule of
Benefits for maximums that may
apply to these types of services
*Important Note:
All Other Services
100%
applies.
145
Not Covered
100%
Not Covered
applies.
90% per visit
Not Covered
applies.
90%
Not Covered
applies.
Allergy Injections
90% per visit
Not Covered
applies.
PLAN FEATURES
Physician
NETWORK
OUT-OF-NETWORK
pays 100%
Paid same as Network benefits
*See Important note below
applies.
*Important Note: Please note that as these providers are not Network Providers and do not have a contract with
Aetna, the provider may not accept payment of your cost share as payment in full. You may receive a bill for the
difference between the amount billed by the provider and the amount paid by this Plan. If the Emergency Room
Facility or physician bills you for an amount above your cost share, you are not responsible for paying that
amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will
resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the
bill.
Not Covered
Not Covered
Important Notice:
A separate hospital emergency room copay applies for each visit to an emergency room for emergency care. If
you are admitted to a hospital as an inpatient immediately following a visit to an emergency room, your copay is
waived.
146
Urgent Medical Care
facility)
pays 90%
Paid same as Network benefits
applies
Urgent Medical Care
(from other than a non-hospital free Services and Physician Services
standing facility)
above.
Provider
Not Covered
above.
Not Covered
Important Notice:
A separate urgent care copay applies for each visit to an urgent care provider for urgent care.
Covered expenses that are applied to the urgent care copay cannot be applied to any other copay under your
plan. Likewise, covered expenses that are applied to your plan’s other copays cannot be applied to the urgent
care copay.
PLAN FEATURES
NETWORK
Complex Imaging
OUT-OF-NETWORK
90% per test
Not Covered
applies
90% per procedure
applies
147
Not Covered
Diagnostic X-Rays
Diagnostic X-Rays (except
Complex Imaging Services)
90% per procedure
Not Covered
applies
PLAN FEATURES
Outpatient Surgery
Outpatient Surgery
NETWORK
OUT-OF-NETWORK
Not Covered
applies
PLAN FEATURES
Birthing Center
Room and Board
NETWORK
OUT-OF-NETWORK
Payable in accordance with the type Not Covered
$100 per admission copay then the
plan pays 90%
Not Covered
applies
90% per admission
Not Covered
applies
plan pays 90%
Not Covered
applies
120 days
Not Covered
148
PLAN FEATURES
Specialty Benefits
Home Health Care(Outpatient)
NETWORK
OUT-OF-NETWORK
pays 100%
Not Covered
applies.
Not Covered
90% per visit
Not Covered
applies
Year
Hospice Benefits
Hospice Care –Facility Expenses
(Room & Board)
Unlimited
Not Covered
plan pays 90%
Not Covered
applies
Hospice Care – Other Expenses
during a stay
90% per admission
Not Covered
applies
Unlimited days
Not Covered
90% per visit
Not Covered
applies.
149
PLAN FEATURES
only.
NETWORK
OUT-OF-NETWORK
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
MENTAL DISORDERS
Room and Board
plan pays 90%
Not Covered
applies.
90% per admission
Not Covered
applies.
Physician Services
90% per admission
Not Covered
applies.
Facility Expenses
plan pays 90%
Not Covered
applies.
Services
90% per visit
Not Covered
applies.
150
Outpatient Services
pays 100%
Not Covered
applies
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Room and Board
Not Covered
plan pays 90%
applies
90% per admission
Not Covered
applies.
Physician Services
90% per admission
Not Covered
applies.
Facility Expenses
plan pays 90%
Not Covered
applies.
Services
90% per visit
Not Covered
applies.
Outpatient Services
pays 100%
applies
151
Not Covered
PLAN FEATURES
NETWORK
Outpatient Obesity Treatment (non $25 per visit copay then the plan
pays 100%
surgical)
OUT-OF-NETWORK
Not Covered
applies.
plan pays 90%
Not Covered
applies
90% per service
Surgery
Not Covered
applies
Unlimited
Not Covered
PLAN FEATURES
NETWORK
NETWORK
(IOE Facility)
(Non-IOE Facility)
$100 per admission
Not Covered
Transplant Facility
copay, then the plan pays
Expenses
90%
OUT-OF-NETWORK
Not Covered
No Calendar Year
deductible applies.
Not Covered
Not Covered
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Acupuncture
in lieu of anesthesia
152
90%
Not Covered
Equipment
90% per item
Not Covered
applies
PLAN FEATURES
NETWORK
OUT-OF-NETWORK
Prosthetic Devices
PLAN FEATURES
NETWORK
Chemotherapy
Infusion Therapy
Radiation Therapy
OUT-OF-NETWORK
PLAN FEATURES
NETWORK
Outpatient Physical,
pays 100%
Occupational, and Speech
Therapy combined
applies
OUT-OF-NETWORK
Combined Physical, Occupational
and Speech Therapy Maximum
Not Covered
60 visits
153
Not Covered
PLAN FEATURES
Spinal Manipulation
NETWORK
OUT-OF-NETWORK
pays 100%
Not Covered
applies.
20 visits
Not Covered
Expense Provisions
Copayment, Copay
Per Admission Copayment
A Per Admission Copayment is an amount you are required to pay when you or a covered dependent have a stay in
an inpatient facility. A copayment is a specified dollar amount or percentage of the negotiated charge required to
be paid by you at the time you receive a covered service from a network provider. It represents a portion of the
applicable expense.
Separate copayments may apply per facility. These copayments are in addition to any other copayments
applicable under this plan. They may apply to each stay or they may apply on a per day basis up to a per admission
maximum amount.
Covered expenses applied to the per admission copayment cannot be applied to any other copayment required in
your plan. Likewise, covered expenses applied to your plan’s other copayments cannot be applied to meet the per
admission copayment.
For the stay of a well newborn baby (starting at birth), the per admission copayment amount will not exceed the
hospital’s actual room and board charge on the first day of the stay.
154
Payment Provisions
Payment Percentage
during the Calendar Year. This Plan has an individual Maximum Out-of-Pocket Limit. As to the individual
Maximum Out-of-Pocket Limit, each of you must meet your Maximum Out-of-Pocket Limit separately and
they cannot be combined and applied towards one limit.
Individual
Once the amount of eligible network provider expenses you or your covered dependents have paid during the
Calendar Year meets the individual Maximum Out-of-Pocket Limit, this Plan will pay 100% of such covered
Year network provider Maximum Out-of-Pocket Limit, these expenses will also count toward a family network
provider Maximum Out-of-Pocket Limit.
To satisfy this family network provider Maximum Out-of-Pocket Limit for the rest of the Calendar Year, the
following must happen:
members. The family network provider Maximum Out-of-Pocket Limit can be met by a combination of
family members with no single individual within the family contributing more than the individual network
provider Maximum Out-of-Pocket Limit amount in a Calendar Year.
 Charges over the recognized charge;
 Expenses incurred for outpatient prescription drugs;
 Non-covered expenses;
 Expenses for non-emergency use of the emergency room;
 Expenses incurred for non-urgent use of an urgent care provider; and
 Expenses that are not paid, or precertification benefit reductions because a required precertification for the
155
General
This Schedule of Benefits replaces any similar Schedule of Benefits previously in effect under your plan of benefits.
Requests for coverage other than that to which you are entitled in accordance with this Schedule of Benefits cannot
be accepted. This Schedule is part of your Benefit Description and should be kept with your Benefit Description.
156
What the Plan Covers and How Benefits Are Paid
Aetna Select EPO
Preface
The medical benefits plan described in this Benefit Description is a benefit plan of the Employer. These benefits are
not insured with Aetna or any of its affiliates, but will be paid from the Employer's funds. Aetna and its HMO
affiliates will provide certain administrative services under the Aetna medical benefits plan.
Aetna agrees with the Employer to provide administrative services in accordance with the conditions, rights, and
privileges as set forth in this Benefit Description. The Employer selects the products and benefit levels under the
Aetna medical benefits plan.
The Benefit Description describes your rights and obligations, what the Aetna medical benefits plan covers, and
how benefits are paid for that coverage. It is your responsibility to understand the terms and conditions in this
Benefit Description. Your Benefit Description includes the Schedule of Benefits and any amendments.
This Benefit Description replaces and supercedes all Aetna Benefit Descriptions describing coverage for the
medical benefits plan described in this Benefit Description that you may previously have received.
Employer:
Contract Number:
Effective Date:
810072
January 1, 2014
Benefits are payable for covered health care expenses that are incurred by you or your covered dependents while
coverage is in effect. An expense is “incurred” on the day you receive a health care service or supply.
Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are
covered.
Refer to the What the Plan Covers section of the Benefit Description for more information about your coverage.
Aetna is not a provider of health care services and therefore is not responsible for and does not guarantee any results
or outcomes of the covered health care services and supplies you receive. Except for Aetna RX Home Delivery LLC,
providers of health care services, including hospitals, institutions, facilities or agencies, are independent contractors
and are neither agents nor employees of Aetna or its affiliates.
Throughout this section you will find information on who can be covered under the plan, how to enroll and what to
do when there is a change in your life that affects coverage. In this section, “you” means the employee.
157
Who Is Eligible
Employees
To be covered by this plan, the following requirements must be met:


You will need to be in an “eligible class,” as defined below; and
You will need to meet the “eligibility date criteria” described below.
Determining if You Are in an Eligible Class
You are in an eligible class if:

You are a regular full-time employee, as defined by your employer.
Probationary Period
Once you enter an eligible class, you will need to complete the probationary period before your coverage under this
plan begins.
Determining When You Become Eligible
You become eligible for the plan on your eligibility date, which is determined as follows.
On the Effective Date of the Plan
If you are in an eligible class on the effective date of this plan, your coverage eligibility date is the effective date of
the plan.
After the Effective Date of the Plan
If you are hired or enter an eligible class after the effective date of this plan, your coverage eligibility date is the first
day of the month coinciding with or next following the date you complete 31 days of continuous service with your
employer. This is defined as the probationary period. If you had already satisfied the probationary period before you
entered the eligible class, your coverage eligibility date is the date you enter the eligible class.
Obtaining Coverage for Dependents
Your dependents can be covered under this Plan. You may enroll the following dependents:




Your spouse.
Your dependent children.
Your domestic partner who meets the rules set by your employer.
Dependent children of your domestic partner.
Aetna will rely upon your employer to determine whether or not a person meets the definition of a dependent for
coverage under this Plan. This determination will be conclusive and binding upon all persons for the purposes of
this Plan.
Coverage for a Domestic Partner
To be eligible for coverage, a domestic partner must meet the following criteria:
A domestic partner is a person who certifies the following as of the date of enrollment:




He or she is your sole domestic partner and intends to remain so indefinitely.
He or she is not married or legally separated from anyone else.
He or she has not registered as a member of another domestic partnership within the past six months.
He or she is of the age of consent in your state of residence.
158





He or she is not a blood relative to a degree of closeness that would prohibit legal marriage in the state in which
you legally reside.
He or she has cohabitated and resided with you in the same residence for the past six months and intends to
cohabitate and reside with you indefinitely.
He or she is engaged with you in a committed relationship of mutual caring and support, and is jointly
responsible for your common welfare and living expenses.
He or she is not in the relationship solely for the purpose of obtaining the benefits of coverage.
He or she can demonstrate interdependence with you by submitting proof of at least three of the following:
 Common ownership of real property (joint deed or mortgage agreement) or a common leasehold interest in
property;
 Common ownership of a motor vehicle;
 Driver’s license listing a common address;
 Proof of joint bank accounts or credit accounts;
 Proof of designation as the primary beneficiary for life insurance or retirement benefits, or primary
beneficiary designation under your will; or
 Assignment of a durable property power of attorney or health care power of attorney.
Coverage for Dependent Children
To be eligible for coverage, a dependent child must be under 26 years of age.
An eligible dependent child includes:







Your biological children;
Your stepchildren;
Your legally adopted children;
Your foster children, including any children placed with you for adoption;
Any children for whom you are responsible under court order;
Your grandchildren in your court-ordered custody; and
Any other child with whom you have a parent-child relationship.
Coverage for a handicapped child may be continued past the age limits shown above. See Handicapped Dependent
Children for more information.
Important Reminder
Keep in mind that you cannot receive coverage under this Plan as:


Both an employee and a dependent; or
A dependent of more than one employee.
How and When to Enroll
Initial Enrollment in the Plan
You will be provided with plan benefit and enrollment information when you first become eligible to enroll. You
will need to enroll in a manner determined by Aetna and your employer. To complete the enrollment process, you
will need to provide all requested information for yourself and your eligible dependents. You will also need to agree
to make required contributions for any contributory coverage. Your employer will determine the amount of your
plan contributions, which you will need to agree to before you can enroll. Your employer will advise you of the
required amount of your contributions and will deduct your contributions from your pay. Remember plan
contributions are subject to change.
You will need to enroll within 31 days of your eligibility date. Otherwise, you may be considered a Late Enrollee. If
159
you miss the enrollment period, you will not be able to participate in the plan until the next annual enrollment period,
unless you qualify under a Special Enrollment Period, as described below.
If you do not enroll for coverage when you first become eligible, but wish to do so later, your employer will provide
you with information on when and how you can enroll.
Newborns are automatically covered for 31 days after birth. To continue coverage after 31 days, you will need to
complete a change form and return it to your employer within the 31-day enrollment period.
Late Enrollment
If you do not enroll during the Initial Enrollment Period, or a subsequent annual enrollment period, you and your
eligible dependents may be considered Late Enrollees and coverage may be deferred until the next annual
enrollment period. If, at the time of your initial enrollment, you elect coverage for yourself only and later request
coverage for your eligible dependents, they may be considered Late Enrollees.
You must return your completed enrollment form before the end of the next annual enrollment period as described
below.
However, you and your eligible dependents may not be considered Late Enrollees if you qualify for one of the
circumstances described in the “Special Enrollment Periods” section below.
Annual Enrollment
During the annual enrollment period, you will have the opportunity to review your coverage needs for the upcoming
year. During this period, you have the option to change your coverage. The choices you make during this annual
enrollment period will become effective the following year.
If you do not enroll yourself or a dependent for coverage when you first become eligible, but wish to do so later, you
will need to do so during the next annual enrollment period, unless you qualify under one of the Special Enrollment
Periods, as described below.
Special Enrollment Periods
You will not be considered a Late Enrollee if you qualify under a Special Enrollment Period as defined below. If
one of these situations applies, you may enroll before the next annual enrollment period.
Loss of Other Health Care Coverage
You or your dependents may qualify for a Special Enrollment Period if:
 You did not enroll yourself or your dependent when you first became eligible or during any subsequent annual
enrollments because, at that time:
 You or your dependents were covered under other creditable coverage; and
 You refused coverage and stated, in writing, at the time you refused coverage that the reason was that you or
your dependents had other creditable coverage; and
 You or your dependents are no longer eligible for other creditable coverage because of one of the following:
 The end of your employment;
 A reduction in your hours of employment (for example, moving from a full-time to part-time position);
 The ending of the other plan’s coverage;
 Death;
 Divorce or legal separation;
 Employer contributions toward that coverage have ended;
 COBRA coverage ends;
 The employer’s decision to stop offering the group health plan to the eligible class to which you belong;
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
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Cessation of a dependent’s status as an eligible dependent as such is defined under this Plan;
With respect to coverage under Medicaid or an S-CHIP Plan, you or your dependents no longer qualify for
such coverage; or
 You or your dependents have reached the lifetime maximum of another Plan for all benefits under that Plan.
You or your dependents become eligible for premium assistance, with respect to coverage under the group
health plan, under Medicaid or an S-CHIP Plan.
You will need to enroll yourself or a dependent for coverage within:
 31 days of when other creditable coverage ends;
 within 60 days of when coverage under Medicaid or an S-CHIP Plan ends; or
 within 60 days of the date you or your dependents become eligible for Medicaid or S-CHIP premium assistance.
Evidence of termination of creditable coverage must be provided to your employer or the party it designates. If you
do not enroll during this time, you will need to wait until the next annual enrollment period.
New Dependents
You and your dependents may qualify for a Special Enrollment Period if:
 You did not enroll when you were first eligible for coverage; and
 You later acquire a dependent, as defined under the plan, through marriage, birth, adoption, or placement for
adoption; and
 You elect coverage for yourself and your dependent within 31 days of acquiring the dependent.
Your spouse or child who meets the definition of a dependent under the plan may qualify for a Special Enrollment
Period if:
 You did not enroll them when they were first eligible; and
 You later elect coverage for them within 31 days of a court order requiring you to provide coverage.
You will need to report any new dependents by completing a change form, which is available from your employer.
The form must be completed and returned to your employer within 31 days of the change. If you do not return the
form within 31 days of the change, you will need to make the changes during the next annual enrollment period.
If You Adopt a Child
Your plan will cover a child who is placed for adoption. This means you have taken on the legal obligation for total
or partial support of a child whom you plan to adopt.
Your plan will provide coverage for a child who is placed with you for adoption if:
 The child meets the plan’s definition of an eligible dependent on the date he or she is placed for adoption; and
 You request coverage for the child in writing within 31 days of the placement;
 Proof of placement will need to be presented to your employer prior to the dependent enrollment;
 Any coverage limitations for a preexisting condition will not apply to a child placed with you for adoption
provided that the placement occurs on or after the effective date of your coverage.
When You Receive a Qualified Child Support Order
A Qualified Medical Child Support Order (QMCSO) is a court order requiring a parent to provide health care
coverage to one or more children. Your plan will provide coverage for a child who is covered under a QMCSO, if:
 The child meets the plan’s definition of an eligible dependent; and
 You request coverage for the child in writing within 31 days of the court order.
Coverage for the dependent will become effective on the date of the court order. Any coverage limitations for a
preexisting condition will not apply, as long as you submit a written request for coverage within the 31-day period.
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If you do not request coverage for the child within the 31-day period, you will need to wait until the next annual
enrollment period.
Under a QMCSO, if you are the non-custodial parent, the custodial parent may file claims for benefits. Benefits for
such claims will be paid to the custodial parent.
Your Effective Date of Coverage
If you have met all the eligibility requirements, your coverage takes effect on the later of:
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The date you are eligible for coverage; and
The date your enrollment information is received; and
The date your required contribution is received by Aetna.
If your completed enrollment information is not received within 31 days of your eligibility date, the rules under the
Important Notice:
You must pay the required contribution in full or coverage will not be effective.
Your Dependent’s Effective Date of Coverage
Your dependent’s coverage takes effect on the same day that your coverage becomes effective, if you have enrolled
them in the plan.
Note: New dependents need to be reported to your employer within 31 days because they may affect your
contributions. If you do not report a new dependent within 31 days of his or her eligibility date, the rules under the
How Your Medical Plan Works
It is important that you have the information and useful resources to help you get the most out of your Aetna
medical plan. This Benefit Description explains:
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What expenses for services and supplies are covered and what limits may apply;
What expenses for services and supplies are not covered by the plan;
Other important information such as eligibility, complaints and appeals, termination, continuation of coverage,
and general administration of the plan.
Important Notes
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Unless otherwise indicated, “you” refers to you and your covered dependents.
Your health plan pays benefits only for services and supplies described in this Benefit Description as covered
expenses that are medically necessary.
This Benefit Description applies to coverage only and does not restrict your ability to receive health care
services that are not or might not be covered benefits under this health plan.
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Common Terms
Many terms throughout this Benefit Description are defined in the Glossary section at the back of this document.
Defined terms appear in bolded print. Understanding these terms will also help you understand how your plan works
and provide you with useful information regarding your coverage.
About Your Aetna Select Medical Plan
This Aetna Select plan provides coverage of medical expenses for the treatment of illness or injury and other
preventive care and routine medical expenses.
With your Aetna Select plan, you can directly access any network physician, hospital or other health care provider
for covered services and supplies under the plan.
Coverage is subject to all the terms, policies, and procedures outlined in this Benefit Description. Not all medical
expenses. Refer to the What the Plan Covers and Exclusions, Limitations sections and the Schedule of Benefits
sections to determine if medical services are covered, excluded or limited.
This Aetna Select plan provides access to covered benefits through a network of health care providers and facilities.
These network physicians, hospitals and other health care professionals have contracted with Aetna or an
affiliate to provide health care services and supplies to Aetna plan members at a reduced fee called the negotiated
charge.
Except for emergency and urgent care services, benefits will only be paid when you utilize network providers and
facilities.
About Your Exclusive Provider Organization (EPO) Medical Plan
This Exclusive Provider Organization (EPO) plan provides coverage of medical expenses for the treatment of
illness or injury and other preventive care and routine medical expenses. With your EPO plan, you can directly
access any network physician, hospital or other health care provider for covered services and supplies under the
plan.
expenses. Refer to the What the Plan Covers and Exclusions, Limitations, sections and the Schedule of Benefits
This EPO plan provides access to covered benefits through a network of health care providers and facilities. These
network physicians, hospitals and other health care professionals have contracted with Aetna or an affiliate to
provide health care services and supplies to Aetna plan members at a reduced fee called the negotiated charge.
facilities.
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About Your Aetna Select Medical Plan
This Aetna select plan provides coverage of medical expenses for the treatment of illness or injury and other
preventive care and routine medical expenses.
expenses. Refer to the What the Plan Covers and Exclusions, Limitations sections and the Schedule of Benefits
This Aetna select plan provides access to covered benefits through a network of health care providers and facilities.
These network physicians, hospitals and other health care professionals have contracted with Aetna or an
affiliate to provide health care services and supplies to Aetna plan members at a reduced fee called the negotiated
charge.
facilities.
Aetna cannot guarantee the availability or continued participation of a particular provider. Either Aetna or any
network provider may terminate the provider contract or limit the number of patients accepted in a practice. If the
physician initially selected cannot accept additional patients, you will be notified and given an opportunity to make
another selection. If the agreement between Aetna and your selected PCP is terminated, Aetna will notify you of
the termination and request you to select another PCP.
Ongoing Reviews:
Aetna conducts ongoing reviews of those services and supplies which are recommended or provided by health
professionals to determine whether such services and supplies are covered benefits under this Benefit Description.
If Aetna determines that the recommended services or supplies are not covered benefits, you will be notified. You
may appeal such determinations by contacting Aetna to seek a review of the determination. Please refer to the
Appeals Procedure and External Reviews sections of this Benefit Description.
How Your Aetna Select Medical Plan Works
The Primary Care Physician:
To access network benefits, you are encouraged to select a Primary Care Physician (PCP) from Aetna’s network
of providers at the time of enrollment. Each covered family member may select his or her own PCP. If your covered
dependent is a minor, or otherwise incapable of selecting a PCP, you should select a PCP on their behalf.
You may search online for the most current list of participating providers in your area by using DocFind, Aetna’s
online provider directory at www.aetna.com. You can choose a PCP based on geographic location, group practice,
medical specialty, language spoken, or hospital affiliation. DocFind is updated several times a week. You may also
request a printed copy of the provider directory through your employer or by contacting Member Services through
e-mail or by calling the toll free number on your ID card.
A PCP may be a general practitioner, family physician, internist, or pediatrician. Your PCP provides routine
preventive care and will treat you for illness or injury.
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A PCP coordinates your medical care, as appropriate either by providing treatment or may direct you to other
network providers for other covered services and supplies. The PCP can also order lab tests and x-rays, prescribe
medicines or therapies, and arrange hospitalization.
Changing Your PCP
You may change your PCP at any time on Aetna’s website, www.aetna.com, or by calling the Member Services
toll-free number on your identification card. The change will become effective upon Aetna’s receipt and approval
of the request.
Specialists and Other Network Providers
You may directly access specialists and other health care professionals in the network for covered services and
supplies under this Benefit Description. Refer to the Aetna provider directory to locate network specialists,
providers and hospitals in your area. Refer to the Schedule of Benefits section for benefit limitations and
out-of-pocket costs applicable to your plan.
Important Note
ID Card: You will receive an ID card. It identifies you as a member when you receive services from health care
providers. If you have not received your ID card or if your card is lost or stolen, notify Aetna immediately and a
new card will be issued.
Accessing Network Providers and Benefits
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You may select a PCP or other direct access network provider from the network provider directory or by
logging on to Aetna’s website at www.aetna.com. You can search Aetna’s online directory, DocFind, for
names and locations of physicians, hospitals and other health care providers and facilities. You can change
your PCP at anytime.
area, please contact Member Services by email or at the toll-free number on your ID card for assistance.
Except for your prescription drug expenses, you will not have to submit medical claims for treatment received
from network health care professionals and facilities. Your network provider will take care of claim
submission. Aetna will directly pay the network provider or facility less any cost sharing required by you.
You will be responsible for deductibles, payment percentage and copayments, if any.
You may be required to pay some network providers at the time of service. When you pay a network
provider directly, you will be responsible for completing a claim form to receive reimbursement of covered
expenses from Aetna. You must submit a completed claim form and proof of payment to Aetna. Refer to the
General Provisions section of this Benefit Description- for a complete description of how to file a claim under
this Plan.
amounts you owe towards any deductible, copayments, or payment percentage amounts or other
non-covered expenses you have incurred. You may elect to receive this notification by e-mail, or through the
mail. Call or e-mail Member Services if you have questions regarding your statement.
Cost Sharing For Network Benefits
Benefits.
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For certain types of services and supplies, you will be responsible for any copayments shown in your Schedule
of Benefits. The copayments will vary depending upon the type of service and whether you obtain covered
health care services from a provider who is a specialist or non-specialist. You will be subject to the PCP
copayments shown on the Schedule of Benefits when you obtain covered health care services from any PCP
who is a network provider. If the provider is a network specialist, then the specialist copayment will apply.
maximum out-of-pocket limit applicable to your plan.
expenses may not apply to the maximum out-of-pocket limits. Refer to your Schedule of Benefits for
You may be billed for any deductible, copayment, or payment percentage amounts, or any non-covered
expenses that you incur.
Emergency and Urgent Care
You have coverage 24 hours a day, 7 days a week, anywhere inside or outside the plan’s service area, for:
 An emergency medical condition; or
 An urgent condition.
In Case of a Medical Emergency
When emergency care is necessary, please follow the guidelines below:
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
Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and
ambulatory assistance. If possible, call your primary care physician provided a delay would not be
detrimental to your health.
After assessing and stabilizing your condition, the emergency room should contact your PCP to obtain your
medical history to assist the emergency physician in your treatment.
If you are admitted to an inpatient facility, notify your PCP as soon as reasonably possible.
If you seek care in an emergency room for a non-emergency condition, the plan will not cover the expenses you
incur. Please refer to the Schedule of Benefits for specific details about the plan. No other plan benefits will pay
for non-emergency care in the emergency room unless otherwise specified under the plan.
Refer to Coverage for Emergency Medical Conditions in the What the Plan Covers section.
In Case of an Urgent Condition
Call your PCP if you think you need urgent care. Network providers are required to provide urgent care coverage
24 hours a day, including weekends and holidays. You may contact any physician or urgent care provider, in- or
out-of-network, for an urgent care condition if you cannot reach your physician.
If it is not feasible to contact your PCP, please do so as soon as possible after urgent care is provided. If you need
help finding a network urgent care provider you may call Member Services at the toll-free number on your I.D.
card, or you may access Aetna’s online provider directory at www.aetna.com.
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Coverage for an Urgent Condition
Refer to Coverage for Urgent Medical Conditions in the What the Plan Covers section.
Non-Urgent Care
If you seek care from an urgent care provider for a non-urgent condition, (one that does not meet the criteria
above), the plan will not cover the expenses you incur unless otherwise specified under the Plan. Please refer to the
Schedule of Benefits for specific plan details.
Important Reminder
the Schedule of Benefits. No other plan benefits will pay for non-urgent care received at a hospital or an urgent care
provider unless otherwise specified.
To keep your out-of-pocket costs lower, your follow-up care should be accessed through your PCP.
Important Notice
Follow up care, which includes (but is not limited to) suture removal, cast removal and radiological tests such as
x-rays, should not be provided by an emergency room facility.
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 Be included as a covered expense in this Benefit Description;
 Not be an excluded expense under this Benefit Description. Refer to the Exclusions sections of this Benefit
Description for a list of services and supplies that are excluded;
 Not exceed the maximums and limitations outlined in this Benefit Description. Refer to the What the Plan
Covers section and the Schedule of Benefits for information about certain expense limits; and
 Be obtained in accordance with all the terms, policies and procedures outlined in this Benefit Description.
2. The service or supply must be provided while coverage is in effect. See the Who Can Be Covered, How and
When to Enroll, When Your Coverage Begins, When Coverage Ends and Continuation of Coverage sections for
details on when coverage begins and ends.
3. The service or supply must be medically necessary. To meet this requirement, the medical services or supply
must be provided by a physician, or other health care provider, exercising prudent clinical judgment, to a
patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its
symptoms. The provision of the service or supply must be:
(a) In accordance with generally accepted standards of medical practice;
(b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for
the patient’s illness, injury or disease; and
(c) Not primarily for the convenience of the patient, physician or other health care provider;
equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury,
or disease.
For these purposes “generally accepted standards of medical practice” means standards that are based on credible
scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical
community, or otherwise consistent with physician specialty society recommendations and the views of physicians
practicing in relevant clinical areas and any other relevant factors.
Important Note
Not every service or supply that fits the definition for medical necessity is covered by the plan. Exclusions and
limitations apply to certain medical services, supplies and expenses. For example some benefits are limited to a
certain number of days, visits or a dollar maximum. Refer to the What the Plan Covers section and the Schedule of
Benefits for the plan limits and maximums.
What the Plan Covers
Aetna Select EPO Medical Plan
Many preventive and routine medical expenses as well as expenses incurred for a serious illness or injury are
covered. This section describes which expenses are covered expenses. Only expenses incurred for the services and
supplies shown in this section are covered expenses. Limitations and exclusions apply.
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Preventive Care
This section on Preventive Care describes the covered expenses for services and supplies provided when you are
well.
Covered expenses include charges made by your primary care physician (PCP) for routine physical exams. This
includes routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a
medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or
injury, and also includes:
•
•
•
•
Evidence-based items that have in effect a rating of A or B in the current recommendations of the United
States Preventive Services Task Force.
Screenings and counseling services as provided for in the comprehensive guidelines recommended by the
Health Resources and Services Administration. These services may include but are not limited to:
- Screening and counseling services, such as:
▫ Interpersonal and domestic violence;
▫ Sexually transmitted diseases; and
▫ Human Immune Deficiency Virus (HIV) infections.
- Screening for gestational diabetes for women.
- High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older.
X-rays, lab and other tests given in connection with the exam.
For covered newborns, an initial hospital check up.
Limitations:
• Services and supplies furnished by an out-of-network provider.
Covered expenses include charges made by your physician or a facility for:
 immunizations for infectious diseases; and
 the materials for administration of immunizations;
that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention.
Limitations
Not covered under this Preventive Care benefit are charges incurred for immunizations that are not considered
Preventive Care such as those required due to your employment or travel.
Covered expenses include charges made by your primary care physician (PCP) for a routine well woman
preventive exam office visit, including Pap smears, in accordance with the recommendations by the Health
Resources and Services Administration. A routine well woman preventive exam is a medical exam given by a
physician for a reason other than to diagnose or treat a suspected or identified illness or injury.
Limitations:
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Covered expenses include, but are not limited to, charges incurred for routine cancer screening as follows:
 Mammograms;
 Fecal occult blood tests;
 Digital rectal exams;
 Prostate specific antigen (PSA) tests;
 Sigmoidoscopies;
 Double contrast barium enemas (DCBE); and
 Colonoscopies.
These benefits will be subject to any age; family history; and frequency guidelines that are:
 Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United
States Preventive Services Task Force; and
 Evidence-informed items or services provided in the comprehensive guidelines supported by the Health
Resources and Services Administration.
Limitations:
Unless specified above, not covered under this benefit are:
 Charges incurred for services which are covered to any extent under any other part of this Plan.
 Services and supplies furnished by an out-of-network provider.
Important Notes:
Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Preventive Care.
For details on the frequency and age limits that apply to Routine Physical Exams and Routine Cancer Screenings,
contact your physician, log onto the Aetna website www.aetna.com, or call member services at the number on the
back of your ID card.
Screening and Counseling Services
Covered expenses include charges made by your primary care physician in an individual or group setting for the
following:
Obesity
Screening and counseling services to aid in weight reduction due to obesity. Coverage includes:
 preventive counseling visits and/or risk factor reduction intervention;
 medical nutrition therapy;
 nutrition counseling; and
 healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known
risk factors for cardiovascular and diet-related chronic disease.
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Screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled
substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured
assessment.
Screening and counseling services to aid in the cessation of the use of tobacco products. Tobacco product means a
substance containing tobacco or nicotine including: cigarettes, cigars; smoking tobacco; snuff; smokeless tobacco
and candy-like products that contain tobacco. Coverage includes:
 preventive counseling visits;
 treatment visits; and
 class visits;
to aid in the cessation of the use of tobacco products.
Limitations:
 Services which are covered to any extent under any other part of this plan;
 Services which are for diagnosis or treatment of a suspected or identified illness or injury;
 Exams given during your stay for medical care;
 Services not given by a physician or under his or her direction;
 Psychiatric, psychological, personality or emotional testing or exams.
Prenatal Care
Prenatal care will be covered as Preventive Care for services received by a pregnant female in a physician's,
obstetrician's, or gynecologist's office but only to the extent described below.
Coverage for prenatal care under this Preventive Care benefit is limited to pregnancy-related physician office visits
including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood
pressure and fetal heart rate check).
Limitations:
• Pregnancy expenses (other than prenatal care as described above); and
• Services and supplies furnished by out-of-network provider.
Important Notes:
Refer to the Pregnancy Expenses and Exclusions sections of this Benefit Description for more
information on coverage for pregnancy expenses under this Plan, including other prenatal care,
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Covered expenses include comprehensive lactation support (assistance and training in breast feeding) and
counseling services provided to females during pregnancy and in the post partum period by a certified lactation
support provider. The "post partum period" means the one-year period directly following the child's date of birth.
Covered expenses incurred during the post partum period also include the rental or purchase of breast feeding
equipment as described below.
Lactation support and lactation counseling services are covered expenses when provided in either a group or
individual setting. Benefits for lactation counseling services are subject to the visit maximum shown in your
Schedule of Benefits.
Breast Feeding Durable Medical Equipment
Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation
support (pumping and storage of breast milk) as follows.
Breast Pump
Covered expenses include the following:
 The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a
hospital.
 The purchase of:
- An electric breast pump (non-hospital grade). A purchase will be covered once every three years; or
- A manual breast pump. A purchase will be covered once every three years.
 If an electric breast pump was purchased within the previous three year period, the purchase of an electric or
manual breast pump will not be covered until a three year period has elapsed from the last purchase of an
electric pump.
Breast Pump Supplies
Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for
the purchase of a new pump.
Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar
purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire cost of any
additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility.
Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of
service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of
Aetna.
Limitations:
 Services which are covered to any extent under any other part of this Plan; and
Important Notes:
If a breast pump service or supply that you need is covered under this Plan but not available from a network
provider in your area, please contact Member Services at the toll-free number on your ID card for assistance.
Family Planning Services - Female Contraceptives
For females with reproductive capacity, covered expenses include those charges incurred for services and supplies
that are provided to prevent pregnancy. All contraceptive methods, services and supplies covered under this
Preventive Care benefit must be approved by the U.S. Food and Drug Administration (FDA).
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Coverage includes counseling services on contraceptive methods provided by a physician, obstetrician or
gynecologist. Such counseling services are covered expenses when provided in either a group or individual setting.
They are subject to the contraceptive counseling services visit maximum shown in your Schedule of Benefits.
The following contraceptive methods are covered expenses under this Preventive Care benefit:
Voluntary Sterilization
Covered expenses include charges billed separately by the provider for female voluntary sterilization procedures
and related services and supplies including, but not limited to, tubal ligation and sterilization implants.
Covered expenses under this Preventive Care benefit would not include charges for a voluntary sterilization
procedure to the extent that the procedure was not billed separately by the provider or because it was not the primary
purpose of a confinement.
Contraceptives
• Female contraceptives that are brand name or generic prescription drugs;
• Female contraceptive devices including the related services and supplies needed to administer the device.
Limitations:
• Services and supplies incurred for an abortion;
• Services which are for the treatment of an identified illness or injury;
• Services that are not given by a physician or under his or her direction;
• Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA;
• Male contraceptive methods, sterilization procedures or devices;
• The reversal of voluntary sterilization procedures, including any related follow-up care;
Family Planning Services - Other
Covered expenses include charges for certain family planning services, even though not provided to treat an illness
or injury.
 Voluntary sterilization for males;
 Voluntary termination of pregnancy.
Limitations:
Not covered are:
 Reversal of voluntary sterilization procedures, including related follow-up care;
 Charges for services which are covered to any extent under any other part of this Plan or any other group plans
sponsored by your employer; and
 Charges incurred for family planning services while confined as an inpatient in a hospital or other facility for
medical care; and
Important Notes:
Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Family Planning
Services - Other. For more information, see the sections on Family Planning Services - Female Contraceptives,
Pregnancy Expenses and Treatment of Infertility in this Benefit Description.
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Physician Services
Physician Visits
Covered medical expenses include charges made by a physician during a visit to treat an illness or injury. The visit
may be at the physician’s office, in your home, in a hospital or other facility during your stay or in an outpatient
facility. Covered expenses also include:
 Immunizations for infectious disease, but not if solely for your employment;
 Allergy testing, treatment and injections; and
 Charges made by the physician for supplies, radiological services, x-rays, and tests provided by the physician.
Surgery
 Performing your surgical procedure;
 Pre-operative and post-operative visits; and
 Consultation with another physician to obtain a second opinion prior to the surgery.
Anesthetics
Covered expenses include charges for the administration of anesthetics and oxygen by a physician, other than the
operating physician, or Certified Registered Nurse Anesthetist (C.R.N.A.) in connection with a covered procedure.
Alternatives to Physician Office Visits
Walk-In Clinic Visits
Covered expenses include charges made by network walk-in clinics for:
 The administration of certain immunizations administered within the scope of the clinic’s license; and
 Individual screening and counseling services to aid you:
 to stop the use of tobacco products;
 in weight reduction due to obesity.
Unless specified above, not covered under this benefit are charges incurred for services and supplies furnished:
 In a group setting for screening and counseling services; and
 By an out-of-network provider
Important Note:
 Not all services are available at all Walk-In Clinics. The types of services offered will vary by the provider and
location of the clinic.
 For a complete description of the screening and counseling services provided on the use of tobacco products and
to aid in weight reduction due to obesity, refer to the Preventive Care Benefits section in this Benefit
Description and the Screening and Counseling Services benefit for a description of these services. These
services may also be obtained from your physician
E-Visits
Covered expenses include charges made by your primary care physician (PCP) for a routine, non-emergency,
medical consultation. You must make your E-visit through an Aetna authorized internet service vendor. You may
have to register with that internet service vendor. Information about providers who are signed up with an authorized
vendor may be found in the provider Directory or online in DocFind on www.Aetna.com or by calling the number
on your identification card.
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Hospital Expenses
Covered medical expenses include services and supplies provided by a hospital during your stay.
Room and Board
Covered expenses include charges for room and board provided at a hospital during your stay. Private room
charges that exceed the hospital’s semi-private room rate are not covered unless a private room is required
because of a contagious illness or immune system problem.
Room and board charges also include:
 Services of the hospital’s nursing staff;
 Admission and other fees;
 General and special diets; and
 Sundries and supplies.
Other Hospital Services and Supplies
Covered expenses include charges made by a hospital for services and supplies furnished to you in connection
with your stay.
Covered expenses include hospital charges for other services and supplies provided, such as:
 Ambulance services.
 Physicians and surgeons.
 Operating and recovery rooms.
 Intensive or special care facilities.
 Administration of blood and blood products, but not the cost of the blood or blood products.
 Radiation therapy.
 Speech therapy, physical therapy and occupational therapy.
 Oxygen and oxygen therapy.
 Radiological services, laboratory testing and diagnostic services.
 Medications.
 Intravenous (IV) preparations.
 Discharge planning.
Outpatient Hospital Expenses
Covered expenses include hospital charges made for covered services and supplies provided by the outpatient
department of a hospital.
Important Reminders
The plan will only pay for nursing services provided by the hospital as part of its charge. The plan does not cover
private duty nursing services as part of an inpatient hospital stay.
If a hospital or other health care facility does not itemize specific room and board charges and other charges,
Aetna will assume that 40 percent of the total is for room and board charge, and 60 percent is for other charges.
In addition to charges made by the hospital, certain physicians and other providers may bill you separately during
your stay.
Refer to the Schedule of Benefits for any applicable deductible, copay and payment percentage and maximum
benefit limits.
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Covered expenses include charges made by a hospital or a physician for services provided in an emergency room
to evaluate and treat an emergency medical condition.
The emergency care benefit covers:
 Use of emergency room facilities;
 Emergency room physicians services;
 Hospital nursing staff services; and
 Radiologists and pathologists services.
Please contact a network provider after receiving treatment for an emergency medical condition.
Important Reminder
With the exception of Urgent Care described below, if you visit a hospital emergency room for a non-emergency
condition, the plan will pay a reduced benefit, as shown in the Schedule of Benefits. No other plan benefits will pay
for non-emergency care in the emergency room.
Coverage for Urgent Conditions
Covered expenses include charges made by a hospital or urgent care provider to evaluate and treat an urgent
condition.
Your coverage includes:
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Use of emergency room facilities when network urgent care facilities are not in the service area and you cannot
reasonably wait to visit your physician;
Use of urgent care facilities;
Physicians services;
Nursing staff services; and
Radiologists and pathologists services.
Please contact your PCP after receiving treatment of an urgent condition.
Alternatives to Hospital Stays
Outpatient Surgery and Physician Surgical Services
Covered expenses include charges for services and supplies furnished in connection with outpatient surgery made
by:
 A physician or dentist for professional services;
 A surgery center; or
 The outpatient department of a hospital.
The surgery must meet the following requirements:
 The surgery can be performed adequately and safely only in a surgery center or hospital and
 The surgery is not normally performed in a physician’s or dentist’s office.
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Important Note
Benefits for surgery services performed in a physician's or dentist's office are described under Physician Services
benefits in the previous section.
The following outpatient surgery expenses are covered:
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Services and supplies provided by the hospital, surgery center on the day of the procedure;
The operating physician’s services for performing the procedure, related pre- and post-operative care, and
administration of anesthesia; and
Services of another physician for related post-operative care and administration of anesthesia. This does not
include a local anesthetic.
Limitations
Not covered under this plan are charges made for:
 The services of a physician or other health care provider who renders technical assistance to the operating
physician.
 A stay in a hospital.
 Facility charges for office based surgery.
Birthing Center
Covered expenses include charges made by a birthing center for services and supplies related to your care in a
birthing center for:
 Prenatal care;
 Delivery; and
 Postpartum care within 48 hours after a vaginal delivery and 96 hours after a Cesarean delivery.
Limitations
Unless specified above, not covered under this benefit are charges:
 In connection with a pregnancy for which pregnancy related expenses are not included as a covered expense.
See Pregnancy Related Expenses for information about other covered expenses related to maternity care.
Home Health Care
Covered expenses include charges made by a home health care agency for home health care, and the care:
 Is given under a home health care plan;
 Is given to you in your home while you are homebound.
Home health care expenses include charges for:
 Part-time or intermittent care by an R.N. or by an L.P.N. if an R.N. is not available.
 Part-time or intermittent home health aid services provided in conjunction with and in direct support of care by
an R.N. or an L.P.N.
 Physical, occupational, and speech therapy.
 Part-time or intermittent medical social services by a social worker when provided in conjunction with, and in
direct support of care by an R.N. or an L.P.N.
 Medical supplies, prescription drugs and lab services by or for a home health care agency to the extent they
would have been covered under this plan if you had a hospital stay.
Benefits for home health care visits are payable up to the Home Health Care Maximum. Each visit by a nurse or
therapist is one visit.
In figuring the Calendar Year Maximum Visits, each visit of up to 4 hours is one visit.
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This maximum will not apply to care given by an R.N. or L.P.N. when:
 Care is provided within 10 days of discharge from a hospital or skilled nursing facility as a full-time inpatient;
and
 Care is needed to transition from the hospital or skilled nursing facility to home care.
When the above criteria are met, covered expenses include up to 12 hours of continuous care by an R.N. or L.P.N.
per day.
Coverage for Home Health Care services is not determined by the availability of caregivers to perform them. The
absence of a person to perform a non-skilled or custodial care service does not cause the service to become covered.
If the covered person is a minor or an adult who is dependent upon others for non-skilled care (e.g. bathing, eating,
toileting), coverage for home health services will only be provided during times when there is a family member or
caregiver present in the home to meet the person’s non-skilled needs.
Limitations
 Services or supplies that are not a part of the Home Health Care Plan.
 Services of a person who usually lives with you, or who is a member of your or your spouse’s or your domestic
partner's family.
 Services of a certified or licensed social worker.
 Services for Infusion Therapy.
 Transportation.
 Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present.
 Services that are custodial care.
Important Reminders
The plan does not cover custodial care, even if care is provided by a nursing professional, and family member or
other caretakers cannot provide the necessary care.
Refer to the Schedule of Benefits for details about any applicable home health care visit maximums.
Private Duty Nursing
Covered expenses include private duty nursing provided by a R.N. or L.P.N. if the person's condition requires
skilled nursing care and visiting nursing care is not adequate. However, covered expenses will not include private
duty nursing for any shifts during a Calendar Year in excess of the Private Duty Nursing Care Maximum Shifts.
Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift.
The plan also covers skilled observation for up to one four-hour period per day, for up to 10 consecutive days
following:
 A change in your medication;
 Treatment of an urgent or emergency medical condition by a physician;
 The onset of symptoms indicating a need for emergency treatment;
 Surgery;
 An inpatient stay.
Limitations
 Nursing care that does not require the education, training and technical skills of a R.N. or L.P.N.
 Nursing care assistance for daily life activities, such as:
 Transportation;
 Meal preparation;
 Vital sign charting;
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 Companionship activities;
 Bathing;
 Feeding;
 Personal grooming;
 Dressing;
 Toileting; and
 Getting in/out of bed or a chair.
Nursing care provided for skilled observation.
Nursing care provided while you are an inpatient in a hospital or health care facility.
A service provided solely to administer oral medicine, except where law requires a R.N. or L.P.N. to administer
medicines.
Covered expenses include charges made by a skilled nursing facility during your stay for the following services
and supplies, up to the maximums shown in the Schedule of Benefits, including:
 Room and board, up to the semi-private room rate. The plan will cover up to the private room rate if it is
needed due to an infectious illness or a weak or compromised immune system;
 Use of special treatment rooms;
 Radiological services and lab work;
 Physical, occupational, or speech therapy;
 Oxygen and other gas therapy;
 Other medical services and general nursing services usually given by a skilled nursing facility (this does not
include charges made for private or special nursing, or physician’s services); and
 Medical supplies.
Important Reminder
Refer to the Schedule of Benefits for details about any applicable skilled nursing facility maximums.
Limitations
 Charges made for the treatment of:
 Drug addiction;
 Alcoholism;
 Senility;
 Mental retardation; or
 Any other mental illness; and
 Daily room and board charges over the semi private rate.
Hospice Care
Covered expenses include charges made by the following furnished to you for hospice care when given as part of
a hospice care program.
Facility Expenses
The charges made by a hospital, hospice or skilled nursing facility for:
 Room and Board and other services and supplies furnished during a stay for pain control and other acute and
chronic symptom management; and
 Services and supplies furnished to you on an outpatient basis.
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Outpatient Hospice Expenses
Covered expenses include charges made on an outpatient basis by a Hospice Care Agency for:
 Part-time or intermittent nursing care by a R.N. or L.P.N. for up to eight hours a day;
 Part-time or intermittent home health aide services to care for you up to eight hours a day.
 Medical social services under the direction of a physician. These include but are not limited to:
 Assessment of your social, emotional and medical needs, and your home and family situation;
 Identification of available community resources; and
 Assistance provided to you to obtain resources to meet your assessed needs.
 Physical and occupational therapy; and
 Consultation or case management services by a physician;
 Medical supplies;
 Prescription drugs;
 Dietary counseling; and
 Psychological counseling.
Charges made by the providers below if they are not an employee of a Hospice Care Agency; and such Agency
retains responsibility for your care:
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A physician for a consultation or case management;
A physical or occupational therapist;
A home health care agency for:
 Part time or intermittent home health aide services for your care up to eight hours a day;
 Medical supplies;
 Prescription drugs;
 Psychological counseling; and
 Dietary counseling.
Limitations
 Daily room and board charges over the semi-private room rate.
 Funeral arrangements.
 Pastoral counseling.
 Financial or legal counseling. This includes estate planning and the drafting of a will.
 Homemaker or caretaker services. These are services which are not solely related to your care. These include,
but are not limited to: sitter or companion services for either you or other family members; transportation;
maintenance of the house.
Important Reminders
Refer to the Schedule of Benefits for details about any applicable hospice care maximums.
Other Covered Health Care Expenses
Acupuncture
The plan covers charges made for acupuncture services provided by a physician, if the service is performed:
 As a form of anesthesia in connection with a covered surgical procedure.
Important Reminder
Refer to the Schedule of Benefits for details about any applicable acupuncture benefit maximum.
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Ambulance Service
Covered expenses include charges made by a professional ambulance, as follows:
Ground Ambulance
Covered expenses include charges for transportation:
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To the first hospital where treatment is given in a medical emergency.
From one hospital to another hospital in a medical emergency when the first hospital does not have the
required services or facilities to treat your condition.
From hospital to home or to another facility when other means of transportation would be considered unsafe
due to your medical condition.
From home to hospital for covered inpatient or outpatient treatment when other means of transportation would
be considered unsafe due to your medical condition. Transport is limited to 100 miles.
When during a covered inpatient stay at a hospital, skilled nursing facility or acute rehabilitation hospital, an
ambulance is required to safely and adequately transport you to or from inpatient or outpatient medically
necessary treatment.
Air or Water Ambulance
Covered expenses include charges for transportation to a hospital by air or water ambulance when:
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Ground ambulance transportation is not available; and
Your condition is unstable, and requires medical supervision and rapid transport; and
In a medical emergency, transportation from one hospital to another hospital; when the first hospital does not
have the required services or facilities to treat your condition and you need to be transported to another
hospital; and the two conditions above are met.
Limitations
Not covered under this benefit are charges incurred to transport you:
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If an ambulance service is not required by your physical condition; or
If the type of ambulance service provided is not required for your physical condition; or
By any form of transportation other than a professional ambulance service.
Diagnostic and Preoperative Testing
Diagnostic Complex Imaging Expenses
The plan covers charges made on an outpatient basis by a physician, hospital or a licensed imaging or radiological
facility for complex imaging services to diagnose an illness or injury, including:
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C.A.T. scans;
Magnetic Resonance Imaging (MRI);
Positron Emission Tomography (PET) Scans; and
Any other outpatient diagnostic imaging service costing over $500.
Complex Imaging Expenses for preoperative testing will be payable under this benefit.
Limitations
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Outpatient Diagnostic Lab Work and Radiological Services
Covered expenses include charges for radiological services (other than diagnostic complex imaging), lab services,
and pathology and other tests provided to diagnose an illness or injury. You must have definite symptoms that start,
maintain or change a plan of treatment prescribed by a physician. The charges must be made by a physician,
hospital or licensed radiological facility or lab.
Important Reminder
Refer to the Schedule of Benefits for details about any deductible, payment percentage and maximum that may
apply to outpatient diagnostic testing, and lab and radiological services.
Outpatient Preoperative Testing
Prior to a scheduled covered surgery, covered expenses include charges made for tests performed by a hospital,
surgery center, physician or licensed diagnostic laboratory provided the charges for the surgery are covered
expenses and the tests are:
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Related to your surgery, and the surgery takes place in a hospital or surgery center;
Completed within 14 days before your surgery;
Performed on an outpatient basis;
Covered if you were an inpatient in a hospital;
Not repeated in or by the hospital or surgery center where the surgery will be performed.
Test results should appear in your medical record kept by the hospital or surgery center where the surgery is
performed.
Limitations
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If your tests indicate that surgery should not be performed because of your physical condition, the plan will pay
for the tests, however surgery will not be covered.
Important Reminder
Complex Imaging testing for preoperative testing is covered under the complex imaging section. Separate cost
sharing may apply. Refer to your Schedule of Benefits for information on cost sharing amounts for complex
imaging.
Covered expenses include charges by a DME supplier for the rental of equipment or, in lieu of rental:
The initial purchase of DME if:
 Long term care is planned; and
 The equipment cannot be rented or is likely to cost less to purchase than to rent.
Repair of purchased equipment. Maintenance and repairs needed due to misuse or abuse are not covered.
Replacement of purchased equipment if:
 The replacement is needed because of a change in your physical condition; and
 It is likely to cost less to replace the item than to repair the existing item or rent a similar item.
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The plan limits coverage to one item of equipment, for the same or similar purpose and the accessories needed to
operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment
you purchase or rent for personal convenience or mobility.
Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the
Exclusions section of this Benefit Description. Aetna reserves the right to limit the payment of charges up to the
most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The
decision to rent or purchase is at the discretion of Aetna.
Important Reminder
Refer to the Schedule of Benefits for details about durable medical and surgical equipment deductible, payment
percentage and benefit maximums. Also refer to Exclusions for information about Home and Mobility exclusions.
Experimental or Investigational Treatment
Covered expenses include charges made for experimental or investigational drugs, devices, treatments or
procedures, provided all of the following conditions are met:
 You have been diagnosed with cancer or a condition likely to cause death within one year or less;
 Standard therapies have not been effective or are inappropriate;
 Aetna determines, based on at least two documents of medical and scientific evidence, that you would likely
benefit from the treatment;
 There is an ongoing clinical trial. You are enrolled in a clinical trial that meets these criteria:
 The drug, device, treatment or procedure to be investigated has been granted investigational new drug (IND) or
Group c/treatment IND status;
 The clinical trial has passed independent scientific scrutiny and has been approved by an Institutional Review
Board that will oversee the investigation;
 The clinical trial is sponsored by the National Cancer Institute (NCI) or similar national organization (such as
the Food & Drug Administration or the Department of Defense) and conforms to the NCI standards;
 The clinical trial is not a single institution or investigator study unless the clinical trial is performed at an
NCI-designated cancer center; and
 You are treated in accordance with protocol.
Pregnancy Related Expenses
Covered expenses include charges made by a physician for pregnancy and childbirth services and supplies at the
same level as any illness or injury. This includes prenatal visits, delivery and postnatal visits.
For inpatient care of the mother and newborn child, covered expenses include charges made by a Hospital for a
minimum of:
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48 hours after a vaginal delivery; and
96 hours after a cesarean section.
A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn
earlier.
Covered expenses also include charges made by a birthing center as described under Alternatives to Hospital
Care.
Note: Covered expenses also include services and supplies provided for circumcision of the newborn during the
stay.
Important Note:
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Refer to the Preventive Care section of this Benefit Description for additional information on coverage
for female contraceptive coverage under this Plan.
Prosthetic Devices
Covered expenses include charges made for internal and external prosthetic devices and special appliances, if the
device or appliance improves or restores body part function that has been lost or damaged by illness, injury or
congenital defect. Covered expenses also include instruction and incidental supplies needed to use a covered
prosthetic device.
The plan covers the first prosthesis you need that temporarily or permanently replaces all or part of a body part lost
or impaired as a result of disease or injury or congenital defects as described in the list of covered devices below for
an:
 Internal body part or organ; or
 External body part.
Covered expenses also include replacement of a prosthetic device if:
 The replacement is needed because of a change in your physical condition; or normal growth or wear and tear;
or
 It is likely to cost less to buy a new one than to repair the existing one; or
 The existing one cannot be made serviceable.
The list of covered devices includes but is not limited to:
 An artificial arm, leg, hip, knee or eye;
 Eye lens;
 An external breast prosthesis and the first bra made solely for use with it after a mastectomy;
 A breast implant after a mastectomy;
 Ostomy supplies, urinary catheters and external urinary collection devices;
 Speech generating device;
 A cardiac pacemaker and pacemaker defibrillators; and
 A durable brace that is custom made for and fitted for you.
The plan will not cover expenses and charges for, or expenses related to:
 Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet; unless the orthopedic
shoe is an integral part of a covered leg brace; or
 Trusses, corsets, and other support items; or
 Any item listed in the Exclusions section.
Short-Term Rehabilitation Therapy Services
Covered expenses include charges for short-term therapy services when prescribed by a physician as described
below up to the benefit maximums listed on your Schedule of Benefits. The services have to be performed by:
 A licensed or certified physical, occupational or speech therapist;
 A hospital, skilled nursing facility, or hospice facility; or
 A physician.
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Charges for the following short term rehabilitation expenses are covered:
Cardiac and Pulmonary Rehabilitation Benefits.
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Cardiac rehabilitation benefits are available as part of an inpatient hospital stay. A limited course of outpatient
cardiac rehabilitation is covered when following angioplasty, cardiovascular surgery, congestive heart failure or
myocardial infarction. The plan will cover charges in accordance with a treatment plan as determined by your
risk level when recommended by a physician. This course of treatment is limited to a maximum of 36 sessions
in a 12 week period.
Pulmonary rehabilitation benefits are available as part of an inpatient hospital stay. A limited course of
outpatient pulmonary rehabilitation is covered for the treatment of reversible pulmonary disease states. This
course of treatment is limited to a maximum of 36 hours or a six week period.
Outpatient Cognitive Therapy, Physical Therapy, Occupational Therapy and Speech
Therapy Rehabilitation Benefits.
Coverage is subject to the limits, if any, shown on the Schedule of Benefits. Inpatient rehabilitation benefits for the
services listed will be paid as part of your Inpatient Hospital and Skilled Nursing Facility benefits provision in this
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Physical therapy is covered for non-chronic conditions and acute illnesses and injuries, provided the therapy
expects to significantly improve, develop or restore physical functions lost or impaired as a result of an acute
illness, injury or surgical procedure. Physical therapy does not include educational training or services
designed to develop physical function.
Occupational therapy (except for vocational rehabilitation or employment counseling) is covered for
non-chronic conditions and acute illnesses and injuries, provided the therapy expects to significantly improve,
develop or restore physical functions lost or impaired as a result of an acute illness, injury or surgical procedure,
or to relearn skills to significantly improve independence in the activities of daily living. Occupational therapy
does not include educational training or services designed to develop physical function.
Speech therapy is covered for non-chronic conditions and acute illnesses and injuries and expected to restore
the speech function or correct a speech impairment resulting from illness or injury; or for delays in speech
function development as a result of a gross anatomical defect present at birth. Speech function is the ability to
express thoughts, speak words and form sentences. Speech impairment is difficulty with expressing one’s
thoughts with spoken words.
Cognitive therapy associated with physical rehabilitation is covered when the cognitive deficits have been
acquired as a result of neurologic impairment due to trauma, stroke, or encephalopathy, and when the therapy is
part of a treatment plan intended to restore previous cognitive function.
A “visit” consists of no more than one hour of therapy. Refer to the Schedule of Benefits for the visit maximum that
applies to the plan. Covered expenses include charges for two therapy visits of no more than one hour in a 24-hour
period.
The therapy should follow a specific treatment plan that:
 Details the treatment, and specifies frequency and duration; and
 Provides for ongoing reviews and is renewed only if continued therapy is appropriate.
Important Reminder
Refer to the Schedule of Benefits for details about the short-term rehabilitation therapy maximum benefit.
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Reconstructive or Cosmetic Surgery and Supplies
Covered expenses include charges made by a physician, hospital, or surgery center for reconstructive services
and supplies, including:
 Surgery needed to improve a significant functional impairment of a body part.
 Surgery to correct the result of an accidental injury, including subsequent related or staged surgery, provided
that the surgery occurs no more than 24 months after the original injury. For a covered child, the time period for
coverage may be extended through age 18.
 Surgery to correct the result of an injury that occurred during a covered surgical procedure provided that the
reconstructive surgery occurs no more than 24 months after the original injury.
Note: Injuries that occur as a result of a medical (i.e., non surgical) treatment are not considered accidental injuries,
even if unplanned or unexpected.
 Surgery to correct a gross anatomical defect present at birth or appearing after birth (but not the result of an
illness or injury) when
 the defect results in severe facial disfigurement, or
 the defect results in significant functional impairment and the surgery is needed to improve function
Reconstructive Breast Surgery
Covered expenses include reconstruction of the breast on which a mastectomy was performed, including an
implant and areolar reconstruction. Also included is surgery on a healthy breast to make it symmetrical with the
reconstructed breast and physical therapy to treat complications of mastectomy, including lymphedema.
Important Notice
A benefit maximum may apply to reconstructive or cosmetic surgery services. Please refer to the Schedule of
Benefits.
Specialized Care
Chemotherapy
Covered expenses include charges for chemotherapy treatment. Coverage levels depend on where treatment is
received. In most cases, chemotherapy is covered as outpatient care. Inpatient hospitalization for chemotherapy is
limited to the initial dose while hospitalized for the diagnosis of cancer and when a hospital stay is otherwise
medically necessary based on your health status.
Radiation Therapy Benefits
Covered expenses include charges for the treatment of illness by x-ray, gamma ray, accelerated particles, mesons,
neutrons, radium or radioactive isotopes.
Outpatient Infusion Therapy Benefits
Covered expenses include charges made on an outpatient basis for infusion therapy by:
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A free-standing facility;
The outpatient department of a hospital; or
A physician in his/her office or in your home.
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Infusion therapy is the intravenous or continuous administration of medications or solutions that are a part of your
course of treatment. Charges for the following outpatient Infusion Therapy services and supplies are covered
expenses:
 The pharmaceutical when administered in connection with infusion therapy and any medical supplies,
equipment and nursing services required to support the infusion therapy;
 Professional services;
 Total parenteral nutrition (TPN);
 Chemotherapy;
 Drug therapy (includes antibiotic and antivirals);
 Pain management (narcotics); and
 Hydration therapy (includes fluids, electrolytes and other additives).
Not included under this infusion therapy benefit are charges incurred for:
 Enteral nutrition;
 Blood transfusions and blood products;
 Dialysis; and
 Insulin.
Coverage is subject to the maximums, if any, shown in the Schedule of Benefits.
Coverage for inpatient infusion therapy is provided under the Inpatient Hospital and Skilled Nursing Facility
Benefits sections of this Benefit Description.
Benefits payable for infusion therapy will not count toward any applicable Home Health Care maximums.
Important Reminder
Refer to the Schedule of Benefits for details on any applicable deductible, payment percentage and maximum
benefit limits.
Treatment of Infertility
Covered expenses include charges made by a network physician to diagnose and to surgically treat the underlying
medical cause of infertility.
Spinal Manipulation Treatment
Covered expenses include charges made by a physician on an outpatient basis for manipulative (adjustive)
treatment or other physical treatment for conditions caused by (or related to) biomechanical or nerve conduction
disorders of the spine.
Your benefits are subject to the maximum shown in the Schedule of Benefits. However, this maximum does not
apply to expenses incurred:
 During your hospital stay; or
 For surgery. This includes pre- and post-surgical care provided or ordered by the operating physician.
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Transplant Services
Covered expenses include charges incurred during a transplant occurrence. The following will be considered to be
one transplant occurrence once it has been determined that you or one of your dependents may require an organ
transplant. Organ means solid organ; stem cell; bone marrow; and tissue.
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Heart;
Lung;
Heart/Lung;
Simultaneous Pancreas Kidney (SPK);
Pancreas;
Kidney;
Liver;
Intestine;
Bone Marrow/Stem Cell;
Multiple organs replaced during one transplant surgery;
Tandem transplants (Stem Cell);
Sequential transplants;
Re-transplant of same organ type within 180 days of the first transplant;
Any other single organ transplant, unless otherwise excluded under the plan.
The following will be considered to be more than one Transplant Occurrence:
 Autologous blood/bone marrow transplant followed by allogenic blood/bone marrow transplant (when not part
of a tandem transplant);
 Allogenic blood/bone marrow transplant followed by an autologous blood/bone marrow transplant (when not
part of a tandem transplant);
 Re-transplant after 180 days of the first transplant;
 Pancreas transplant following a kidney transplant;
 A transplant necessitated by an additional organ failure during the original transplant surgery/process;
 More than one transplant when not performed as part of a planned tandem or sequential transplant, (e.g., a liver
transplant with subsequent heart transplant).
The network level of benefits is paid only for a treatment received at a facility designated by the plan as an Institute
of Excellence™ (IOE) for the type of transplant being performed. Each IOE facility has been selected to perform
only certain types of transplants.
Services obtained from a facility that is not designated as an IOE for the transplant being performed will be covered
as out-of-network services and supplies, even if the facility is a network facility or IOE for other types of services.
The plan covers:
 Charges made by a physician or transplant team.
 Charges made by a hospital, outpatient facility or physician for the medical and surgical expenses of a live
donor, but only to the extent not covered by another plan or program.
 Related supplies and services provided by the facility during the transplant process. These services and supplies
may include: physical, speech and occupational therapy; bio-medicals and immunosuppressants; home health
care expenses and home infusion services.
 Charges for activating the donor search process with national registries.
 Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this
coverage, an “immediate” family member is defined as a first-degree biological relative. These are your
biological parents, siblings or children.
 Inpatient and outpatient expenses directly related to a transplant.
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Covered transplant expenses are typically incurred during the four phases of transplant care described below.
Expenses incurred for one transplant during these four phases of care will be considered one transplant occurrence.
A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either 180 days
from the date of the transplant; or upon the date you are discharged from the hospital or outpatient facility for the
admission or visit(s) related to the transplant, whichever is later.
The four phases of one transplant occurrence and a summary of covered transplant expenses during each phase are:
5. Pre-transplant evaluation/screening: Includes all transplant-related professional and technical components
required for assessment, evaluation and acceptance into a transplant facility’s transplant program;
6. Pre-transplant/candidacy screening: Includes HLA typing/compatibility testing of prospective organ donors
who are immediate family members;
7. Transplant event: Includes inpatient and outpatient services for all covered transplant-related health services
and supplies provided to you and a donor during the one or more surgical procedures or medical therapies for a
transplant; prescription drugs provided during your inpatient stay or outpatient visit(s), including bio-medical
and immunosuppressant drugs; physical, speech or occupational therapy provided during your inpatient stay or
outpatient visit(s); cadaveric and live donor organ procurement; and
8. Follow-up care: Includes all covered transplant expenses; home health care services; home infusion services;
and transplant-related outpatient services rendered within 180 days from the date of the transplant event.
If you are a participant in the IOE program, the program will coordinate all solid organ and bone marrow
transplants and other specialized care you need. Any covered expenses you incur from an IOE facility will be
considered network care expenses.
Important Reminders
Refer to the Schedule of Benefits for details about transplant expense maximums, if applicable.
Limitations
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Outpatient drugs including bio-medicals and immunosuppressants not expressly related to an outpatient
Services that are covered under any other part of this plan;
Services and supplies furnished to a donor when the recipient is not covered under this plan;
Home infusion therapy after the transplant occurrence;
Harvesting or storage of organs, without the expectation of immediate transplantation for an existing illness;
Harvesting and/or storage of bone marrow, tissue or stem cells, without the expectation of transplantation
within 12 months for an existing illness;
Cornea (Corneal Graft with Amniotic Membrane) or Cartilage (autologous chondrocyte or autologous
osteochondral mosaicplasty) transplants, unless otherwise authorized by Aetna.
Network of Transplant Specialist Facilities
Through the IOE network, you will have access to a provider network that specializes in transplants. Benefits may
vary if an IOE facility or non-IOE or out-of-network provider is used. In addition, some expenses are payable
only within the IOE network. The IOE facility must be specifically approved and designated by Aetna to perform
the procedure you require. Each facility in the IOE network has been selected to perform only certain types of
transplants, based on quality of care and successful clinical outcomes.
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Obesity Treatment
Covered expenses include charges made by a physician, licensed or certified dietician, nutritionist or hospital for
the non-surgical treatment of obesity for the following outpatient weight management services:
 An initial medical history and physical exam;
 Diagnostic tests given or ordered during the first exam; and
 Prescription drugs.
Morbid Obesity Surgical Expenses
Covered medical expenses include charges made by a hospital or a physician for the surgical treatment of morbid
obesity of a covered person.
Coverage includes the following expenses as long as they are incurred within a two-year period:
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One morbid obesity surgical procedure including complications directly related to the surgery;
Pre-surgical visits;
Related outpatient services; and
One follow-up visit.
This two-year period begins with the date of the first morbid obesity surgical procedure, unless a multi-stage
procedure is planned.
Complications, other than those directly related to the surgery, will be covered under the related medical plan's
covered medical expenses, subject to plan limitations and maximums.
Limitations
 Morbid obesity surgical benefits provided by out-of-network providers.
 Weight control services including surgical procedures, medical treatments, weight control/loss programs,
dietary regimens and supplements, food or food supplements, appetite suppressants and other medications;
exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to
control weight or treat obesity, including morbid obesity, or for the purpose of weight reduction, regardless of
the existence of comorbid conditions; except as provided in the Benefit Description; and
Important Reminder
Refer to the Schedule of Benefits for information about any applicable benefit maximums that apply to morbid
obesity treatment.
Treatment of Mental Disorders and Substance Abuse
Treatment of Mental Disorders
Covered expenses include charges made for the treatment of mental disorders by behavioral health providers.
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Important Note
Not all types of services are covered. For example, educational services and certain types of therapies are not
covered. See Medical Plan Exclusions for more information.
In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
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There is a written treatment plan supervised by a physician or licensed provider; and
The Plan is for a condition that can favorably be changed.
Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or
behavioral health provider's office for the treatment of mental disorders as follows:
Inpatient Treatment
Covered expenses include charges for room and board at the semi-private room rate, and other services and
supplies provided during your stay in a hospital, psychiatric hospital or residential treatment facility. Inpatient
benefits are payable only if your condition requires services that are only available in an inpatient setting.
Partial Confinement Treatment
Covered expenses include charges made for partial confinement treatment provided in a facility or program for
the intermediate short-term or medically-directed intensive treatment of a mental disorder. Such benefits are
payable if your condition requires services that are only available in a partial confinement treatment setting.
Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital,
psychiatric hospital or residential treatment facility.
The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a
facility or program for the intermediate short-term or medically-directed intensive treatment. The partial
hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of
facility.
Important Reminder
 Please refer to the Schedule of Benefits for any copayments/deductibles, maximums, payment limits or
maximum out of pocket limits that may apply to your mental disorders benefits.
Treatment of Substance Abuse
Covered expenses include charges made for the treatment of substance abuse by behavioral health providers.
Important Note
Not all types of services are covered. For example, educational services and certain types of therapies are not
covered. See Medical Plan Exclusions for more information.
Substance Abuse
In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
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There is a written treatment plan supervised by a physician or licensed provider; and
The plan is for a condition that can be favorably changed.
Please refer to the Schedule of Benefits for any substance abuse deductibles, maximums and payment limits or
maximum out of pocket limits that may apply to your substance abuse benefits.
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Inpatient Treatment
This Plan covers room and board at the semi-private room rate and other services and supplies provided during
your stay in a psychiatric hospital or residential treatment facility, appropriately licensed by the state
Department of Health or its equivalent.
Coverage includes:
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Treatment in a hospital for the medical complications of substance abuse.
“Medical complications” include detoxification, electrolyte imbalances, malnutrition, cirrhosis of the liver,
delirium tremens and hepatitis.
Treatment in a hospital is covered only when the hospital does not have a separate treatment facility section.
Outpatient treatment includes charges for treatment received for substance abuse while not confined as a
full-time inpatient in a hospital, psychiatric hospital or residential treatment facility.
This Plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a
facility or program for the intermediate short-term or medically-directed intensive treatment of alcohol or drug
abuse. The partial hospitalization will only be covered if you would need inpatient treatment if you were not
admitted to this type of facility.
Covered expenses include charges made for partial confinement treatment provided in a facility or program for
the intermediate short-term or medically-directed intensive treatment of substance abuse.
Such benefits are payable if your condition requires services that are only available in a partial confinement
treatment setting.
Important Reminder
 Please refer to the Schedule of Benefits for any copayments/deductibles, maximums, payment limits or
maximum out of pocket limits that may apply to your substance abuse benefits.
Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth)
Covered expenses include charges made by a physician, a dentist and hospital for:
 Non-surgical treatment of infections or diseases of the mouth, jaw joints or supporting tissues.
Services and supplies for treatment of, or related conditions of, the teeth, mouth, jaws, jaw joints or supporting
tissues, (this includes bones, muscles, and nerves), for surgery needed to:
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Treat a fracture, dislocation, or wound.
Cut out teeth that are partly or completely impacted in the bone of the jaw; teeth that will not erupt through the
gum; other teeth that cannot be removed without cutting into bone; the roots of a tooth without removing the
entire tooth; cysts, tumors, or other diseased tissues.
Cut into gums and tissues of the mouth. This is only covered when not done in connection with the removal,
replacement or repair of teeth.
Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result
in functional improvement.
Hospital services and supplies received for a stay required because of your condition.
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Dental work, surgery and orthodontic treatment needed to remove, repair, restore or reposition:
(c) Natural teeth damaged, lost, or removed; or
(d) Other body tissues of the mouth fractured or cut
due to injury.
Any such teeth must have been free from decay or in good repair, and are firmly attached to the jaw bone at the time
of the injury.
The treatment must be completed in the Calendar Year of the accident or in the next Calendar Year.
If crowns, dentures, bridges, or in-mouth appliances are installed due to injury, covered expenses only include
charges for:
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The first denture or fixed bridgework to replace lost teeth;
The first crown needed to repair each damaged tooth; and
An in-mouth appliance used in the first course of orthodontic treatment after the injury.
Medical Plan Exclusions
Not every medical service or supply is covered by the plan, even if prescribed, recommended, or approved by your
physician or dentist. The plan covers only those services and supplies that are medically necessary and included in
the What the Plan Covers section. Charges made for the following are not covered except to the extent listed under
the What The Plan Covers section or by amendment attached to this Benefit Description.
Acupuncture, acupressure and acupuncture therapy, except as provided in the What the Plan Covers section.
Allergy: Specific non-standard allergy services and supplies, including but not limited to, skin titration (Rinkel
method), cytotoxicity testing (Bryan’s Test) treatment of non-specific candida sensitivity, and urine autoinjections.
Any non-emergency charges incurred outside of the United States if you traveled to such location to obtain
prescription drugs or supplies, even if otherwise covered under this Benefit Description. This also includes
prescription drugs or supplies if:
 such prescription drugs or supplies are unavailable or illegal in the United States, or
 the purchase of such prescription drugs or supplies outside the United States is considered illegal.
Applied Behavioral Analysis, the LEAP, TEACCH, Denver and Rutgers programs.
Behavioral Health Services:
 Alcoholism or substance abuse rehabilitation treatment on an inpatient or outpatient basis, except to the extent
coverage for detoxification or treatment of alcoholism or substance abuse is specifically provided in the What
the Medical Plan Covers Section.
 Treatment of a covered health care provider who specializes in the mental health care field and who receives
treatment as a part of their training in that field.
 Treatment of impulse control disorders such as pathological gambling, kleptomania, pedophilia, caffeine or
nicotine use.
 Treatment of antisocial personality disorder.
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Treatment in wilderness programs or other similar programs.
Treatment of mental retardation, defects, and deficiencies. This exclusion does not apply to mental health
services or to medical treatment of mentally retarded in accordance with the benefits provided in the What the
Plan Covers section of this Benefit Description.
Blood, blood plasma, synthetic blood, blood products or substitutes, including but not limited to, the provision of
blood, other than blood derived clotting factors. Any related services including processing, storage or replacement
costs, and the services of blood donors, apheresis or plasmapheresis are not covered. For autologous blood
donations, only administration and processing costs are covered.
Charges for a service or supply furnished by a network provider in excess of the negotiated charge.
Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage under the
plan.
Charges submitted for services by an unlicensed hospital, physician or other provider or not within the scope of the
provider’s license.
Contraception, except as specifically described in the What the Plan Covers Section:
 Over the counter contraceptive supplies including but not limited to condoms, contraceptive foams, jellies and
ointments.
Cosmetic services and plastic surgery: any treatment, surgery (cosmetic or plastic), service or supply to alter,
improve or enhance the shape or appearance of the body whether or not for psychological or emotional reasons
including:
 Face lifts, body lifts, tummy tucks, liposuctions, removal of excess skin, removal or reduction of non-malignant
moles, blemishes, varicose veins, cosmetic eyelid surgery and other surgical procedures;
 Procedures to remove healthy cartilage or bone from the nose (even if the surgery may enhance breathing) or
other part of the body;
 Chemical peels, dermabrasion, laser or light treatments, bleaching, creams, ointments or other treatments or
supplies to alter the appearance or texture of the skin;
 Insertion or removal of any implant that alters the appearance of the body (such as breast or chin implants);
except removal of an implant will be covered when medically necessary;
 Removal of tattoos (except for tattoos applied to assist in covered medical treatments, such as markers for
radiation therapy); and
 Repair of piercings and other voluntary body modifications, including removal of injected or implanted
substances or devices;
 Surgery to correct Gynecomastia;
 Breast augmentation;
 Otoplasty.
Counseling: Services and treatment for marriage, religious, family, career, social adjustment, pastoral, or financial
counselor except as specifically provided in the What the Plan Covers section.
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Custodial Care
Dental Services: any treatment, services or supplies related to the care, filling, removal or replacement of teeth and
the treatment of injuries and diseases of the teeth, gums, and other structures supporting the teeth. This includes but
is not limited to:
 services of dentists, oral surgeons, dental hygienists, and orthodontists including apicoectomy (dental root
resection), root canal treatment, soft tissue impactions, treatment of periodontal disease, alveolectomy,
augmentation and vestibuloplasty and fluoride and other substances to protect, clean or alter the appearance of
teeth;
 dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth guards, and
other devices to protect, replace or reposition teeth; and
 non-surgical treatments to alter bite or the alignment or operation of the jaw, including treatment of
malocclusion or devices to alter bite or alignment.
This exclusion does not include removal of bony impacted teeth, bone fractures, removal of tumors and
orthodontogenic cysts.
Disposable outpatient supplies: Any outpatient disposable supply or device, including sheaths, bags, elastic
garments, support hose, bandages, bedpans, syringes, blood or urine testing supplies, and other home test kits; and
splints, neck braces, compresses, and other devices not intended for reuse by another patient.
Drugs, medications and supplies:
 Over-the-counter drugs, biological or chemical preparations and supplies that may be obtained without a
prescription including vitamins;
 Any services related to the dispensing, injection or application of a drug;
 Any prescription drug purchased illegally outside the United States, even if otherwise covered under this plan
within the United States;
 Immunizations related to work;
 Needles, syringes and other injectable aids, except as covered for diabetic supplies;
 Drugs related to the treatment of non-covered expenses;
 Performance enhancing steroids;
 Injectable drugs if an alternative oral drug is available;
 Outpatient prescription drugs;
 Self-injectable prescription drugs and medications;
 Any prescription drugs, injectibles, or medications or supplies provided by the customer or through a third
party vendor contract with the customer; and
 Charges for any prescription drug for the treatment of erectile dysfunction, impotence, or sexual dysfunction or
inadequacy.
Durable medical and surgical equipment including purchase, rental, replacement or repair from an
out-of-network provider, except as specifically provided in the What the Plan Covers section.
Educational services:
 Any services or supplies related to education, training or retraining services or testing, including: special
education, remedial education, job training and job hardening programs;
 Evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental, learning and
communication disorders, behavioral disorders, (including pervasive developmental disorders) training or
cognitive rehabilitation, regardless of the underlying cause; and
 Services, treatment, and educational testing and training related to behavioral (conduct) problems, learning
disabilities and delays in developing skills.
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Examinations:
 Any health examinations required:
 by a third party, including examinations and treatments required to obtain or maintain employment, or
which an employer is required to provide under a labor agreement;
 by any law of a government;
 for securing insurance, school admissions or professional or other licenses;
 to travel;
 to attend a school, camp, or sporting event or participate in a sport or other recreational activity; and
Any special medical reports not directly related to treatment except when provided as part of a covered service.
Experimental or investigational drugs, devices, treatments or procedures, except as described in the What the
Plan Covers section.
Facility charges for care services or supplies provided in:
 rest homes;
 assisted living facilities;
 similar institutions serving as an individual's primary residence or providing primarily custodial or rest care;
 health resorts;
 spas, sanitariums; or
 infirmaries at schools, colleges, or camps.
Food items: Any food item, including infant formulas, nutritional supplements, vitamins, including prescription
vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition. This exclusion does not
apply to specialized medical foods delivered enterally (only when delivered via a tube directly into the stomach or
intestines) or parenterally.
Foot care: Any services, supplies, or devices to improve comfort or appearance of toes, feet or ankles, including but
not limited to:
 Treatment of calluses, bunions, toenails, hammer-toes, subluxations, fallen arches, weak feet, chronic foot pain
or conditions caused by routine activities such as walking, running, working or wearing shoes; and
 Shoes (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards, protectors,
creams, ointments and other equipment, devices and supplies, even if required following a covered treatment of
an illness or injury.
Growth/Height: Any treatment, device, drug, service or supply (including surgical procedures, devices to stimulate
growth and growth hormones), solely to increase or decrease height or alter the rate of growth.
Hearing:
 Any hearing service or supply that does not meet professionally accepted standards;
 Hearing exams given during a stay in a hospital or other facility; and
 Any tests, appliances, and devices for the improvement of hearing (including hearing aids and amplifiers), or to
enhance other forms of communication to compensate for hearing loss or devices that simulate speech.
Home and mobility: Any addition or alteration to a home, workplace or other environment, or vehicle and any
related equipment or device, such as:
 Purchase or rental of exercise equipment, air purifiers, central or unit air conditioners, water purifiers,
waterbeds. and swimming pools;
 Exercise and training devices, whirlpools, portable whirlpool pumps, sauna baths, or massage devices;
 Equipment or supplies to aid sleeping or sitting, including non-hospital electric and air beds, water beds, pillows,
sheets, blankets, warming or cooling devices, bed tables and reclining chairs;
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Equipment installed in your home, workplace or other environment, including stair-glides, elevators,
wheelchair ramps, or equipment to alter air quality, humidity or temperature;
Other additions or alterations to your home, workplace or other environment, including room additions,
changes in cabinets, countertops, doorways, lighting, wiring, furniture, communication aids, wireless alert
systems, or home monitoring;
Services and supplies furnished mainly to provide a surrounding free from exposure that can worsen your
illness or injury;
Removal from your home, worksite or other environment of carpeting, hypo-allergenic pillows, mattresses,
paint, mold, asbestos, fiberglass, dust, pet dander, pests or other potential sources of allergies or illness; and
Transportation devices, including stair-climbing wheelchairs, personal transporters, bicycles, automobiles,
vans or trucks, or alterations to any vehicle or transportation device.
Home births: Any services and supplies related to births occurring in the home or in a place not licensed to perform
deliveries.
Infertility: except as specifically described in the What the Plan Covers Section, any services, treatments,
procedures or supplies that are designed to enhance fertility or the likelihood of conception, including but not
limited to:
 Injectable infertility medications, including but not limited to menotropins, hCG, GnRH agonists, and IVIG;
 Artificial Insemination;
 Any advanced reproductive technology (“ART”) procedures or services related to such procedures, including
but not limited to in vitro fertilization (“IVF”), gamete intra-fallopian transfer (“GIFT”), zygote intra-fallopian
transfer (“ZIFT”), and intra-cytoplasmic sperm injection (“ICSI”); Artificial Insemination for covered females
attempting to become pregnant who are not infertile as defined by the plan;
 Infertility services for couples in which 1 of the partners has had a previous sterilization procedure, with or
without surgical reversal;
 Procedures, services and supplies to reverse voluntary sterilization;
charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers or
surrogacy; donor egg retrieval or fees associated with donor egg programs, including but not limited to fees for
laboratory tests;
ultrasounds, laboratory tests, etc.); any charges associated with a frozen embryo or egg transfer, including but
not limited to thawing charges;
 Home ovulation prediction kits or home pregnancy tests;
 Any charges associated with care required to obtain ART Services (e.g., office, hospital, ultrasounds,
laboratory tests); and any charges associated with obtaining sperm for any ART procedures; and
Maintenance Care.
Medicare: Payment for that portion of the charge for which Medicare or another party is the primary payer.
 Annual or other charges to be in a physician’s practice;
 Charges to have preferred access to a physician’s services such as boutique or concierge physician practices;
 Cancelled or missed appointment charges or charges to complete claim forms;
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Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient did not
have coverage (to the extent exclusion is permitted by law) including:
 Care for conditions related to current or previous military service;
 Care while in the custody of a governmental authority;
 Any care a public hospital or other facility is required to provide; or
 Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity,
except to the extent coverage is required by applicable laws.
Nursing and home health aide services provided outside of the home (such as in conjunction with school, vacation,
work or recreational activities).
Non-medically necessary services, including but not limited to, those treatments, services, prescription drugs and
supplies which are not medically necessary, as determined by Aetna, for the diagnosis and treatment of illness,
injury, restoration of physiological functions, or covered preventive services. This applies even if they are
prescribed, recommended or approved by your physician or dentist.
Personal comfort and convenience items: Any service or supply primarily for your convenience and personal
comfort or that of a third party, including: Telephone, television, internet, barber or beauty service or other guest
services; housekeeping, cooking, cleaning, shopping, monitoring, security or other home services; and travel,
transportation, or living expenses, rest cures, recreational or diversional therapy.
Private duty nursing during your stay in a hospital, and outpatient private duty nursing services, except as
specifically described in the Private Duty Nursing provision in the What the Plan Covers Section.
Sex change: Any treatment, drug, service or supply related to changing sex or sexual characteristics, including:
 Surgical procedures to alter the appearance or function of the body;
 Hormones and hormone therapy;
 Prosthetic devices; and
 Medical or psychological counseling.
Services provided by a spouse, domestic partner, parent, child, step-child, brother, sister, in-law or any household
member.
Services of a resident physician or intern rendered in that capacity.
Services provided where there is no evidence of pathology, dysfunction, or disease; except as specifically provided
in connection with covered routine care and cancer screenings.
Sexual dysfunction/enhancement: Any treatment, drug, service or supply to treat sexual dysfunction, enhance
sexual performance or increase sexual desire, including:
 Surgery, drugs, implants, devices or preparations to correct or enhance erectile function, enhance sensitivity, or
alter the shape or appearance of a sex organ; and
 Sex therapy, sex counseling, marriage counseling or other counseling or advisory services.
Services, including those related to pregnancy, rendered before the effective date or after the termination of
coverage, unless coverage is continued under the Continuation of Coverage section of this Benefit Description.
Services that are not covered under this Benefit Description.
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Services and supplies provided by an out-of-network provider.
Speech therapy for treatment of delays in speech development, except as specifically provided in the What the
Medical Plan Covers Section. For example, the plan does not cover therapy when it is used to improve speech skills
that have not fully developed.
Spinal disorder, including care in connection with the detection and correction by manual or mechanical means of
structural imbalance, distortion or dislocation in the human body or other physical treatment of any condition
caused by or related to biomechanical or nerve conduction disorders of the spine including manipulation of the
spine treatment, except as specifically provided in the What the Plan Covers section.
Strength and performance: Services, devices and supplies to enhance strength, physical condition, endurance or
physical performance, including:
 Exercise equipment, memberships in health or fitness clubs, training, advice, or coaching;
 Drugs or preparations to enhance strength, performance, or endurance; and
 Treatments, services and supplies to treat illnesses, injuries or disabilities related to the use of
performance-enhancing drugs or preparations.
defects amenable to surgical repair (such as cleft lip/palate), are not covered. Examples of non-covered diagnoses
include Pervasive Developmental Disorders (including Autism), Down Syndrome, and Cerebral Palsy, as they are
considered both developmental and/or chronic in nature.
Therapies and tests: Any of the following treatments or procedures:
 Aromatherapy;
 Bio-feedback and bioenergetic therapy;
 Carbon dioxide therapy;
 Chelation therapy (except for heavy metal poisoning);
 Computer-aided tomography (CAT) scanning of the entire body;
 Educational therapy;
 Gastric irrigation;
 Hair analysis;
 Hyperbaric therapy, except for the treatment of decompression or to promote healing of wounds;
 Hypnosis, and hypnotherapy, except when performed by a physician as a form of anesthesia in connection with
covered surgery;
 Lovaas therapy;
 Massage therapy;
 Megavitamin therapy;
 Primal therapy;
 Psychodrama;
 Purging;
 Recreational therapy;
 Rolfing;
 Sensory or auditory integration therapy;
 Sleep therapy;
 Thermograms and thermography.
Tobacco Use: Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products
or to treat or reduce nicotine addiction, dependence or cravings, including counseling, hypnosis and other therapies,
medications, nicotine patches and gum except as specifically provided in the What the Plan Covers section.
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Transplant-The transplant coverage does not include charges for:
 Services and supplies furnished to a donor when recipient is not a covered person;
 Harvesting and/or storage of organs, without the expectation of immediate transplantation for an existing
illness;
 Harvesting and/or storage of bone marrow, tissue or stem cells without the expectation of transplantation within
12 months for an existing illness;
 Cornea (corneal graft with amniotic membrane) or cartilage (autologous chondrocyte or autologous
osteochondral mosaicplasty) transplants, unless otherwise precertified by Aetna.
Transportation costs, including ambulance services for routine transportation to receive outpatient or inpatient
services except as described in the What the Plan Covers section.
Unauthorized services, including any service obtained by or on behalf of a covered person without Precertification
by Aetna when required. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation.
Vision-related services and supplies, except as described in the What the Plan Covers section. The plan does not
cover:
 Special supplies such as non-prescription sunglasses and subnormal vision aids;
 Vision service or supply which does not meet professionally accepted standards;
 Eye exams during your stay in a hospital or other facility for health care;
 Eye exams for contact lenses or their fitting;
 Eyeglasses or duplicate or spare eyeglasses or lenses or frames;
 Replacement of lenses or frames that are lost or stolen or broken;
 Acuity tests;
 Eye surgery for the correction of vision, including radial keratotomy, LASIK and similar procedures;
 Services to treat errors of refraction.
Weight: Any treatment, drug service or supply intended to decrease or increase body weight, control weight or treat
obesity, including morbid obesity, regardless of the existence of comorbid conditions; except as specifically
provided in the What the Plan Covers section, including but not limited to:

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Liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery; surgical procedures
medical treatments, weight control/loss programs and other services and supplies that are primarily intended to
treat, or are related to the treatment of obesity, including morbid obesity;
Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food or food
supplements, appetite suppressants and other medications;
Counseling, coaching, training, hypnosis or other forms of therapy; and
Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or other
forms of activity or activity enhancement.
Work related: Any illness or injury related to employment or self-employment including any illness or injury that
arises out of (or in the course of) any work for pay or profit, unless no other source of coverage or reimbursement is
available to you for the services or supplies. Sources of coverage or reimbursement may include your employer,
workers’ compensation, or an occupational illness or similar program under local, state or federal law. A source of
coverage or reimbursement will be considered available to you even if you waived your right to payment from that
source. If you are also covered under a workers’ compensation law or similar law, and submit proof that you are not
covered for a particular illness or injury under such law, that illness or injury will be considered
“non-occupational” regardless of cause.
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When Coverage Ends
Coverage under your plan can end for a variety of reasons. In this section, you will find details on how and why
coverage ends, and how you may still be able to continue coverage.
When Coverage Ends for Employees
Your Aetna health benefits coverage will end if:
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The Aetna health benefits plan is discontinued;
You voluntarily stop your coverage;
You are no longer eligible for coverage;
You do not make any required contributions;
You become covered under another plan offered by your employer;
You have exhausted your overall maximum lifetime benefit under your health plan, if your plan contains such a
maximum benefit; or
Your employer notifies Aetna that your employment is ended.
It is your employer’s responsibility to let Aetna know when your employment ends.
Your Proof of Prior Medical Coverage
Under the Health Insurance Portability and Accountability Act of 1996, your employer is required to give you a
certificate of creditable coverage when your employment ends. This certificate proves that you were covered under
this plan when you were employed. Ask your employer about the certificate of creditable coverage.
When Coverage Ends for Dependents
Coverage for your dependents will end if:
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You are no longer eligible for dependents’ coverage;
You do not make your contribution for the cost of dependents’ coverage;
Your own coverage ends for any of the reasons listed under When Coverage Ends for Employees. (This does
not apply if you use up your overall lifetime maximum, if included);
Your dependent is no longer eligible for coverage. Coverage ends at the end of the calendar month when your
dependent does not meet the plan’s definition of a dependent; or
As permitted under applicable federal and state law, your dependent becomes eligible for like benefits under
this or any other group plan offered by your employer.
In addition, a "domestic partner" will no longer be considered to be a defined dependent on the earlier to occur of:


The date this plan no longer allows coverage for domestic partners.
The date of termination of the domestic partnership.
Coverage for dependents may continue for a period after your death. Coverage for handicapped dependents may
continue after they reach any limiting age. See Continuation of Coverage for more information.
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Health Expense Coverage for your fully handicapped dependent child may be continued past the maximum age for
a dependent child. However, such coverage may not be continued if the child has been issued an individual medical
conversion policy.
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he or she is not able to earn his or her own living because of mental retardation or a physical handicap which
started prior to the date he or she reaches the maximum age for dependent children under your plan; and
he or she depends chiefly on you for support and maintenance.
Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date your child
reaches the maximum age under your plan.
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
Cessation of the handicap.
Failure to give proof that the handicap continues.
Failure to have any required exam.
Termination of Dependent Coverage as to your child for any reason other than reaching the maximum age under
your plan.
Aetna will have the right to require proof of the continuation of the handicap. Aetna also has the right to examine
your child as often as needed while the handicap continues at its own expense. An exam will not be required more
often than once each year after 2 years from the date your child reached the maximum age under your plan.
If your employer is subject to COBRA requirements, the health plan continuation is governed by the Federal
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requirements. With COBRA you and your
dependents can continue health coverage, subject to certain conditions and your payment of contributions.
Continuation rights are available following a “qualifying event” that would cause you or family members to
otherwise lose coverage. Qualifying events are listed in this section.
Continuing Coverage through COBRA
When you or your covered dependents become eligible, your employer will provide you with detailed information
on continuing your health coverage through COBRA.
You or your dependents will need to:

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
Complete and submit an application for continued health coverage, which is an election notice of your intent to
continue coverage.
Submit your application within 60 days of the qualifying event, or within 60 days of your employer’s notice of
this COBRA continuation right, if later.
Agree to pay the required contributions.
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Who Qualifies for COBRA
You have 60 days from the qualifying event to elect COBRA. If you do not submit an application within 60 days,
you will forfeit your COBRA continuation rights.
Below you will find the qualifying events and a summary of the maximum coverage periods according to COBRA
requirements.
Qualifying Event Causing Loss
of Health Coverage
Your active employment ends for
reasons other than gross
misconduct
Your working hours are reduced
You divorce or legally separate and
are no longer responsible for
dependent coverage
You become entitled to benefits
under Medicare
Your covered dependent children
no longer qualify as dependents
under the plan
You die
You are a retiree eligible for health
coverage and your former
employer files for bankruptcy
Covered Persons Eligible to
Elect Continuation
Maximum Continuation Periods
Your dependents
18 months
36 months
Your dependents
36 months
Your dependent children
36 months
Your dependents
36 months
18 months
18 months
Disability May Increase Maximum Continuation to 29 Months
If You or Your Covered Dependents Are Disabled
If you or your covered dependent qualify for disability status under Title II or XVI of the Social Security Act during
the 18 month continuation period, you or your covered dependent:

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

Have the right to extend coverage beyond the initial 18 month maximum continuation period.
Qualify for an additional 11 month period, subject to the overall COBRA conditions.
Must notify your employer within 60 days of the disability determination status and before the 18 month
continuation period ends.
Must notify the employer within 30 days after the date of any final determination that you or a covered
dependent is no longer disabled.
Are responsible to pay the contributions after the 18th month, through the 29th month.
If There Are Multiple Qualifying Events
A covered dependent could qualify for an extension of the 18 or 29 month continuation period by meeting the
requirements of another qualifying event, such as divorce or death. The total continuation period, however, can
never exceed 36 months.
Determining Your Contributions For Continuation Coverage
Your contributions are regulated by law, based on the following:


For the 18 or 36 month periods, contributions may never exceed 102 percent of the plan costs.
During the 18 through 29 month period, contributions for coverage during an extended disability period may
never exceed 150 percent of the plan costs.
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When You Acquire a Dependent During a Continuation Period
If through birth, adoption or marriage, you acquire a new dependent during the continuation period, your dependent
can be added to the health plan for the remainder of the continuation period if:

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
He or she meets the definition of an eligible dependent,
Your employer is notified about your dependent within 31 days of eligibility, and
Additional contributions for continuation are paid on a timely basis.
Important Note
For more information about dependent eligibility, see the Eligibility, Enrollment and Effective Date section.
When Your COBRA Continuation Coverage Ends
Your COBRA coverage will end when the first of the following events occurs:

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
You or your covered dependents reach the maximum COBRA continuation period – the end of the 18, 29 or 36
months. (Coverage for a newly acquired dependent who has been added for the balance of a continuation period
would end at the same time your continuation period ends, if he or she is not disabled nor eligible for an
extended maximum).
You or your covered dependents do not pay required contributions.
You or your covered dependents become covered under another group plan that does not restrict coverage for
preexisting conditions. If your new plan limits preexisting condition coverage, the continuation coverage under
this plan may remain in effect until the preexisting clause ceases to apply or the maximum continuation period
is reached under this plan.
The date your employer no longer offers a group health plan.
The date you or a covered dependent becomes enrolled in benefits under Medicare. This does not apply if it is
contrary to the Medicare Secondary Payer Rules or other federal law.
You or your dependent dies.
Coordination of Benefits – What Happens When There is More Than One
Health Plan
Some persons have health coverage in addition to coverage under this Plan. Under these circumstances, it is not
intended that a plan provide duplicate benefits. For this reason, many plans, including this Plan, have a
"coordination of benefits" provision.
Under the coordination of benefits provision of this Plan, the amount normally reimbursed under this Plan is
reduced to take into account payments made by "other plans".
When this and another health expenses coverage plan applies, the order in which the various plans will pay benefits
must be figured. This will be done as follows using the first rule that applies:
1. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a plan which
contains such rules.
2. A plan which covers a person other than as a dependent will be deemed to pay its benefits before a plan which
covers the person as a dependent; except that if the person is also a Medicare beneficiary and as a result of the
Social Security Act of 1965, as amended, Medicare is:
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The benefits of a plan which covers the person as a dependent will be determined before the benefits of a plan
which:
3. Except in the case of a dependent child whose parents are divorced or separated; the plan which covers the
person as a dependent of a person whose birthday comes first in a calendar year will be primary to the plan
which covers the person as a dependent of a person whose birthday comes later in that calendar year. If both
parents have the same birthday, the benefits of a plan which covered one parent longer are determined before
those of a plan which covered the other parent for a shorter period of time.
If the other plan does not have the rule described in this provision (3) but instead has a rule based on the gender
of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will
determine the order of benefits.
d. If there is a court decree which states that the parents shall share joint custody of a dependent child, without
stating that one of the parents is responsible for the health care expenses of the child, the order of benefit
determination rules specified in (3) above will apply.
e. If there is a court decree which makes one parent financially responsible for the medical, dental or other
health care expenses of such child, the benefits of a plan which covers the child as a dependent of such
parent will be determined before the benefits of any other plan which covers the child as a dependent child.
f. If there is not such a court decree:

If the parent with custody of the child has not remarried, the benefits of a plan which covers the child as
a dependent of the parent with custody of the child will be determined before the benefits of a plan
which covers the child as a dependent of the parent without custody.
 If the parent with custody of the child has remarried, the benefits of a plan which covers the child as a
child as a dependent of the stepparent. The benefits of a plan which covers that child as a dependent of
the stepparent will be determined before the benefits of a plan which covers that child as a dependent of
the parent without custody.
5. If 1, 2, 3 and 4 above do not establish an order of payment, the plan under which the person has been covered for
the longest will be deemed to pay its benefits first; except that:
 the dependent of such person.
 dependent of such person.
The benefits of a plan which covers the person on whose expenses claim is based under a right of continuation
pursuant to federal or state law shall be determined after the benefits of any other plan which covers the person
other than under such right of continuation.
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The general rule is that the benefits otherwise payable under this Plan for all expenses processed during a single
"processed claim transaction" will be reduced by the total benefits payable under all "other plans" for the same
expenses. An exception to this rule is that when the coordination of benefits rules of this Plan and any "other plan"
both agree that this Plan is primary, the benefits of the other plan will be ignored in applying this rule. As used in
this paragraph, a "processed claim transaction" is a group of actual or prospective charges submitted to Aetna for
consideration, that have been grouped together for administrative purposes as a "claim transaction" in accordance
with Aetna's then current rules. If the contract includes both medical and dental coverage, those coverages will be
considered separate plans. The Medical/Pharmacy coverage will be coordinated with other Medical/Pharmacy plans.
In turn, the dental coverage will be coordinated with other dental plans.
In order to administer this provision, Aetna can release or obtain data. Aetna can also make or recover payments.
Other Plan
 Group insurance.
 Any other type of coverage for persons in a group. This includes plans that are insured and those that are not.
 No-fault auto insurance required by law and provided on other than a group basis. Only the level of benefits
required by the law will be counted.
When You Have Medicare Coverage
Effect of Medicare


is covered under it;
is not covered under it because of:

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
All health expenses covered under this Plan will be reduced by any Medicare benefits available for those
expenses. This will be done before the health benefits of this Plan are figured.
Charges used to satisfy a person's Part B deductible under Medicare will be applied under this Plan in the order
received by Aetna. Two or more charges received at the same time will be applied starting with the largest first.
Medicare benefits will be taken into account for any person while he or she is eligible for Medicare. This will be
done whether or not he or she is entitled to Medicare benefits.
Any rule for coordinating "other plan" benefits with those under this Plan will be applied after this Plan's
benefits have been figured under the above rules. Allowable Expenses will be reduced by any Medicare benefits
available for those expenses.
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Coverage will not be changed at any time when your Employer's compliance with federal law requires this Plan's
benefits for a person to be figured before benefits are figured under Medicare.
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General Provisions
Type of Coverage
Coverage under the plan is non-occupational. Only non-occupational accidental injuries and non-occupational
illnesses are covered. The plan covers charges made for services and supplies only while the person is covered
under the plan.
Aetna will have the right and opportunity to examine and evaluate any person who is the basis of any claim at all
reasonable times while a claim is pending or under review. This will be done at no cost to you.
Legal Action
No legal action can be brought to recover payment under any benefit after 3 years from the deadline for filing
claims.
 This Benefit Description applies to coverage only, and does not restrict your ability to receive health care
services that are not, or might not be, covered.
 You cannot receive multiple coverage under the plan because you are connected with more than one employer.
 In the event of a misstatement of any fact affecting your coverage under the plan, the true facts will be used to
determine the coverage in force.
 This document describes the main features of the plan. If you have any questions about the terms of the plan or
about the proper payment of benefits, contact your employer or Aetna.
 The plan may be changed or discontinued with respect to your coverage.
Assignments
Coverage and your rights under this plan may not be assigned. A direction to pay a provider is not an assignment of
any right under this plan or of any legal or equitable right to institute any court proceeding.
Misstatements
Aetna’s failure to implement or insist upon compliance with any provision of this plan at any given time or times,
shall not constitute a waiver of Aetna’s right to implement or insist upon compliance with that provision at any
other time or times.
Fraudulent misstatements in connection with any claim or application for coverage may result in termination of all
coverage under this plan.
Rescission of Coverage
Aetna may rescind your coverage if you, or the person seeking coverage on your behalf:
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
Performs an act, practice or omission that constitutes fraud; or
Makes an intentional misrepresentation of material fact.
You will be given 30 days advance written notice of any rescission of coverage.
As to medical and prescription drug coverage only, you have the right to an internal Appeal with Aetna and/or the
right to a third party review conducted by an independent External Review Organization if your coverage under this
Benefit Description is rescinded retroactive to its Effective Date.
Subrogation and Right of Recovery Provision
The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or
other representative of a dependent child who incurs claims and is or has been covered by the plan. The plan's right
to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, your
decedents, minors, and incompetent or disabled persons. "You" or "your" includes anyone on whose behalf the plan
pays benefits. No adult covered person hereunder may assign any rights that it may have to recover medical
expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person
without the prior express written consent of the plan.
The plan's right of subrogation or reimbursement, as set forth below, extend to all insurance coverage available to
you due to an injury, illness or condition for which the plan has paid medical claims (including, but not limited to,
liability coverage, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage,
medical payments coverage, workers' compensation coverage, no-fault automobile coverage or any first party
insurance coverage).
Your health plan is always secondary to automobile no-fault coverage, personal injury protection coverage, or
medical payments coverage.
Subrogation
The right of subrogation means the plan is entitled to pursue any claims that you may have in order to recover the
benefits paid by the plan. Immediately upon paying or providing any benefit under the plan, the plan shall be
subrogated to (stand in the place of) all rights of recovery with respect to any claim or potential claim against any
party, due to an injury, illness or condition to the full extent of benefits provided or to be provided by the plan. The
plan may assert a claim or file suit in your name and take appropriate action to assert its subrogation claim, with or
without your consent. The plan is not required to pay you part of any recovery it may obtain, even if it files suit in
your name.
Reimbursement
If you receive any payment as a result of an injury, illness or condition, you agree to reimburse the plan first from
such payment for all amounts the plan has paid and will pay as a result of that injury, illness or condition, up to and
including the full amount of your recovery.
Constructive Trust
By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any provider)
you agree that if you receive any payment as a result of an injury, illness or condition, you will serve as a
constructive trustee over those funds. Failure to hold such funds in trust will be deemed a breach of your fiduciary
duty to the plan.
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Lien Rights
Further, the plan will automatically have a lien to the extent of benefits paid by the plan for the treatment of the
illness, injury or condition upon any recovery whether by settlement, judgment, or otherwise, related to treatment
for any illness, injury or condition for which the plan paid benefits. The lien may be enforced against any party who
possesses funds or proceeds representing the amount of benefits paid by the plan including, but not limited to, you,
your representative or agent, and/or any other source possessing funds representing the amount of benefits paid by
the plan.
Assignment
In order to secure the plan's recovery rights, you agree to assign to the plan any benefits or claims or rights of
recovery you have under any automobile policy or other coverage, to the full extent of the plan's subrogation and
reimbursement claims. This assignment allows the plan to pursue any claim you may have, whether or not you
choose to pursue the claim.
First-Priority Claim
By accepting benefits from the plan, you acknowledge that the plan’s recovery rights are a first priority claim and
are to be repaid to the plan before you receive any recovery for your damages. The plan shall be entitled to full
reimbursement on a first-dollar basis from any payments, even if such payment to the plan will result in a recovery
which is insufficient to make you whole or to compensate you in part or in whole for the damages sustained. The
plan is not required to participate in or pay your court costs or attorney fees to any attorney you hire to pursue your
damage claim.
Applicability to All Settlements and Judgments
The terms of this entire subrogation and right of recovery provision shall apply and the plan is entitled to full
recovery regardless of whether any liability for payment is admitted and regardless of whether the settlement or
judgment identifies the medical benefits the plan provided or purports to allocate any portion of such settlement or
judgment to payment of expenses other than medical expenses. The plan is entitled to recover from any and all
settlements or judgments, even those designated as pain and suffering, non-economic damages, and/or general
damages only. The plan's claim will not be reduced due to your own negligence.
Cooperation
You agree to cooperate fully with the plan’s efforts to recover benefits paid. It is your duty to notify the plan within
30 days of the date when any notice is given to any party, including an insurance company or attorney, of your
intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or
condition. You and your agents shall provide all information requested by the plan, the Claims Administrator or its
representative including, but not limited to, completing and submitting any applications or other forms or
statements as the plan may reasonably request and all documents related to or filed in person injury litigation.
Failure to provide this information, failure to assist the plan in pursuit of its subrogation rights, or failure to
reimburse the plan from any settlement or recovery you receive may result in the termination of your health benefits
or the institution of court proceedings against you.
You shall do nothing to prejudice the plan’s subrogation or recovery interest or to prejudice the plan’s ability to
enforce the terms of this plan provision. This includes, but is not limited to, refraining from making any settlement
or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan. If you fail to
cooperate with the plan in its efforts to recover such amounts or do anything to hinder or prevent such a recovery,
you will cease to be entitled to any further plan benefits. The plan will also have the right to withhold or offset future
benefit payments up to the amount of any settlement, judgment, or recovery you obtain, regardless of whether the
settlement, judgment or recovery is designated to cover future medical benefits or expenses.
You acknowledge that the plan has the right to conduct an investigation regarding the injury, illness or condition to
identify potential sources of recovery. The plan reserves the right to notify all parties and his/ her agents of its lien.
Agents include, but are not limited to, insurance companies and attorneys.
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You acknowledge that the plan has notified you that it has the right pursuant to the Health Insurance Portability &
Accountability Act ("HIPAA"), 42 U.S.C. Section 1301 et seq, to share your personal health information in
exercising its subrogation and reimbursement rights.
Interpretation
In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or
questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the plan shall have
the sole authority and discretion to resolve all disputes regarding the interpretation of this provision.
Jurisdiction
By accepting benefits from the plan, you agree that any court proceeding with respect to this provision may be
brought in any court of competent jurisdiction as the plan may elect. By accepting such benefits, you hereby submit
to each such jurisdiction, waiving whatever rights may correspond by reason of your present or future domicile. By
accepting such benefits, you also agree to pay all attorneys' fees the plan incurs in successful attempts to recover
amounts the plan is entitled to under this section.
Workers’ Compensation
If benefits are paid under the Aetna medical benefits plan and Aetna determines you received Workers'
Compensation benefits for the same incident, Aetna has the right to recover as described under the Subrogation and
Right of Reimbursement provision. Aetna, on behalf of the Plan, will exercise its right to recover against you.
The Recovery Rights will be applied even though:




The Workers' Compensation benefits are in dispute or are made by means of settlement or compromise;
No final determination is made that bodily injury or illness was sustained in the course of or resulted from your
employment;
The amount of Workers' Compensation due to medical or health care is not agreed upon or defined by you or the
Workers' Compensation carrier; or
The medical or health care benefits are specifically excluded from the Workers' Compensation settlement or
compromise.
You hereby agree that, in consideration for the coverage provided by this Aetna medical benefits plan, you will
notify Aetna of any Workers' Compensation claim you make, and that you agree to reimburse Aetna, on behalf of
the Plan, as described above.
If benefits are paid under this Aetna medical benefits plan, and you or your covered dependent recover from a
responsible party by settlement, judgment or otherwise, Aetna, on behalf of the Plan, has a right to recover from you
or your covered dependent an amount equal to the amount the Plan paid.
Health Coverage
If a benefit payment is made by the Plan, to or on your behalf, which exceeds the benefit amount that you are
entitled to receive, the Plan has the right:


To require the return of the overpayment; or
To reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that person or
another person in his or her family.
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Reporting of Claims
A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss. Your
employer has claim forms.
If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still be
accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health benefits will not
be covered if they are filed more than 2 years after the deadline.
Payment of Benefits
Benefits will be paid as soon as the necessary proof to support the claim is received. Written proof must be provided
for all benefits.
All covered health benefits are payable to you. However, Aetna has the right to pay any health benefits to the
service provider. This will be done unless you have told Aetna otherwise by the time you file the claim.
The Plan may pay up to $1,000 of any other benefit to any of your relatives whom it believes fairly entitled to it.
This can be done if the benefit is payable to you and you are a minor or not able to give a valid release.
When a PCP provides care for you or a covered dependent, or care is provided by a network provider (network
services or supplies), the network provider will take care of filing claims.
Records of Expenses
Very important are:
 Names of physicians, dentists and others who furnish services.
 Dates expenses are incurred.
 Copies of all bills and receipts.
Contacting Aetna
If you have questions, comments or concerns about your benefits or coverage, or if you are required to submit
information to Aetna, you may contact Aetna’s Home Office at:
Hartford, CT 06156
You may also use Aetna’s toll free Member Services phone number on your ID card or visit Aetna’s web site at
www.aetna.com.
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Effect of Benefits Under Other Plans
Effect of A Health Maintenance Organization Plan (HMO Plan) On Coverage
If you are in an eligible class and have chosen coverage under an HMO Plan offered by your employer, you will be
excluded from medical expense coverage (except Vision Care, if any,) on the date of your coverage under such
HMO Plan.
If you are in an eligible class and are covered under an HMO Plan, you can choose to change to coverage for
yourself and your covered dependents under this plan. If you:



Live in an HMO Plan enrollment area and choose to change coverage during an open enrollment period,
coverage will take effect on the group contract anniversary date after the open enrollment period. There will be
no rules for waiting periods or preexisting conditions.
Live in an HMO Plan enrollment area and choose to change coverage when there is not an open enrollment
period, coverage will take effect only if and when Aetna gives its written consent.
Move from an HMO Plan enrollment area or if the HMO discontinues and you choose to change coverage
within 31 days of the move or the discontinuance, coverage will take effect on the date you elect such coverage.
There will be no restrictions for waiting periods or preexisting conditions. If you choose to change coverage
after 31 days, coverage will take effect only if and when Aetna gives its written consent.
No benefits will be paid for any charges for services rendered or supplies furnished under an HMO Plan.
Discount Programs
From time to time, we may offer, provide, or arrange for discount arrangements or special rates from certain service
providers such as pharmacies, optometrists, dentists, alternative medicine, wellness and healthy living providers to
you under this plan. Some of these arrangements may be made available through third parties who may make
payments to Aetna in exchange for making these services available.
The third party service providers are independent contractors and are solely responsible to you for the provision of
any such goods and/or services. We reserve the right to modify or discontinue such arrangements at any time. These
discount arrangements are not insurance. There are no benefits payable to you nor do we compensate providers for
services they may render through discount arrangements.
Incentives
In order to encourage you to access certain medical services when deemed appropriate by you in consultation with
your physician or other service providers, we may, from time to time, offer to waive or reduce a member’s
copayment, payment percentage, and/or a deductible otherwise required under the plan or offer coupons or other
financial incentives. We have the right to determine the amount and duration of any waiver, reduction, coupon, or
financial incentive and to limit the covered persons to whom these arrangements are available.
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Claims, Appeals and External Review
Filing Health Claims under the Plan
Under the Plan, you may file claims for Plan benefits and appeal adverse claim determinations. Any reference to
“you” in this Claims, Appeals and External Review section includes you and your Authorized Representative. An
"Authorized Representative" is a person you authorize, in writing, to act on your behalf. The Plan will also
recognize a court order giving a person authority to submit claims on your behalf. In the case of an urgent care claim,
a health care professional with knowledge of your condition may always act as your Authorized Representative.
If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna Life Insurance
Company (Aetna). The notice will explain the reason for the denial and the appeal procedures available under the
Plan.
Urgent Care Claims
An “Urgent Care Claim” is any claim for medical care or treatment for which the application of the time periods for
making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain
maximum function, or, in the opinion of a physician with knowledge of your medical condition, would subject you
to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
If the Plan requires advance approval of a service, supply or procedure before a benefit will be payable, and if Aetna
or your physician determines that it is an Urgent Care Claim, you will be notified of the decision, whether adverse or
not, as soon as possible but not later than 72 hours after the claim is received.
If there is not sufficient information to decide the claim, you will be notified of the information necessary to
complete the claim as soon as possible, but not later than 24 hours after receipt of the claim. You will be given a
reasonable additional amount of time, but not less than 48 hours, to provide the information, and you will be notified
of the decision not later than 48 hours after the end of that additional time period (or after receipt of the information,
if earlier).
Other Claims (Pre-Service and Post-Service)
If the Plan requires you to obtain advance approval of a non-urgent service, supply or procedure before a benefit
will be payable, a request for advance approval is considered a pre-service claim. You will be notified of the
decision not later than 15 days after receipt of the pre-service claim.
For other claims (post-service claims), you will be notified of the decision not later than 30 days after receipt of the
claim.
For either a pre-service or a post-service claim, these time periods may be extended up to an additional 15 days due
to circumstances outside Aetna’s control. In that case, you will be notified of the extension before the end of the
initial 15 or 30-day period. For example, they may be extended because you have not submitted sufficient
information, in which case you will be notified of the specific information necessary and given an additional period
of at least 45 days after receiving the notice to furnish that information. You will be notified of Aetna’s claim
decision no later than 15 days after the end of that additional period (or after receipt of the information, if earlier).
For pre-service claims which name a specific claimant, medical condition, and service or supply for which approval
is requested, and which are submitted to an Aetna representative responsible for handling benefit matters, but which
otherwise fail to follow the Plan's procedures for filing pre-service claims, you will be notified of the failure within
5 days (within 24 hours in the case of an urgent care claim) and of the proper procedures to be followed. The notice
may be oral unless you request written notification.
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If you have received pre-authorization for an ongoing course of treatment, you will be notified in advance if the
previously authorized course of treatment is intended to be terminated or reduced so that you will have an
opportunity to appeal any decision to Aetna and receive a decision on that appeal before the termination or
reduction takes effect. If the course of treatment involves urgent care, and you request an extension of the course of
treatment at least 24 hours before its expiration, you will be notified of the decision within 24 hours after receipt of
the request.
Health Claims – Standard Appeals
As an individual enrolled in the Plan, you have the right to file an appeal from an Adverse Benefit Determination
relating to service(s) you have received or could have received from your health care provider under the Plan.
An “Adverse Benefit Determination” is defined as a denial, reduction, termination of, or failure to, provide or make
payment (in whole or in part) for a service, supply or benefit. Such Adverse Benefit Determination may be based on:
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Your eligibility for coverage, including a retrospective termination of coverage (whether or not there is an
adverse effect on any particular benefit);
Coverage determinations, including plan limitations or exclusions;
The results of any Utilization Review activities;
A decision that the service or supply is experimental or investigational; or
A decision that the service or supply is not medically necessary.
A “Final Internal Adverse Benefit Determination” is defined as an Adverse Benefit Determination that has been
upheld by the appropriate named fiduciary (Aetna) at the completion of the internal appeals process, or an Adverse
Benefit Determination for which the internal appeals process has been exhausted.
Exhaustion of Internal Appeals Process
Generally, you are required to complete all appeal processes of the Plan before being able to obtain External Review
or bring an action in litigation. However, if Aetna, or the Plan or its designee, does not strictly adhere to all claim
determination and appeal requirements under applicable federal law, you are considered to have exhausted the
Plan’s appeal requirements (“Deemed Exhaustion”) and may proceed with External Review or may pursue any
available remedies under §502(a) of ERISA or under state law, as applicable.
There is an exception to the Deemed Exhaustion rule. Your claim or internal appeal may not go straight to External
Review if:
A rule violation was minor and is not likely to influence a decision or harm you; and
It was for a good cause or was beyond Aetna’s or the Plan’s or its designee’s control; and
It was part of an ongoing good faith exchange between you and Aetna or the Plan.
This exception is not available if the rule violation is part of a pattern or practice of violations by Aetna or the Plan.
You may request a written explanation of the violation from the Plan or Aetna, and the Plan or Aetna must provide
such explanation within 10 days, including a specific description of its bases, if any, for asserting that the violation
should not cause the internal claims and appeals process to be deemed exhausted. If an External Reviewer or a court
rejects your request for immediate review on the basis that the plan met the standards for the exception, you have
the right to resubmit and pursue the internal appeal of the claim. In such a case, within a reasonable time after the
External Reviewer or court rejects the claim for immediate review (not to exceed 10 days), you will receive notice
of the opportunity to resubmit and pursue the internal appeal of the claim. Time periods for re-filing the claim shall
begin to run upon your receipt of such notice.
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Full and Fair Review of Claim Determinations and Appeals
Aetna will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by
Aetna (or at the direction of Aetna), or any new or additional rationale as soon as possible and sufficiently in
advance of the date on which the notice of Final Internal Adverse Benefit Determination is provided, to give you a
reasonable opportunity to respond prior to that date.
You may file an appeal in writing to Aetna at the address provided in this Benefit Description, or, if your appeal is of
an urgent nature, you may call Aetna’s Member Services Unit at the toll-free phone number on your ID card. Your
request should include the group name (that is, your employer), your name, member ID, or other identifying
information shown on the front of the Explanation of Benefits form, and any other comments, documents, records
and other information you would like to have considered, whether or not submitted in connection with the initial
claim.
An Aetna representative may call you or your health care provider to obtain medical records and/or other pertinent
information in order to respond to your appeal.
You will have 180 days following receipt of an Adverse Benefit Determination to appeal the determination to Aetna.
You will be notified of the decision not later than 15 days (for pre-service claims) or 30 days (for post-service
claims) after the appeal is received. You may submit written comments, documents, records and other information
relating to your claim, whether or not the comments, documents, records or other information were submitted in
connection with the initial claim. A copy of the specific rule, guideline or protocol relied upon in the Adverse
Benefit Determination will be provided free of charge upon request by you or your Authorized Representative. You
may also request that Aetna provide you, free of charge, copies of all documents, records and other information
relevant to the claim.
If your claim involves urgent care, an expedited appeal may be initiated by a telephone call to the phone number
included in your denial, or to Aetna's Member Services. Aetna's Member Services telephone number is on your
Identification Card. You or your Authorized Representative may appeal urgent care claim denials either orally or in
writing. All necessary information, including the appeal decision, will be communicated between you or your
Authorized Representative and Aetna by telephone, facsimile, or other similar method. You will be notified of the
decision not later than 36 hours after the appeal is received.
If you are dissatisfied with the appeal decision on an urgent care claim, you may file a second level appeal with
Aetna. You will be notified of the decision not later than 36 hours after the appeal is received.
If you are dissatisfied with a pre-service or post-service appeal decision, you may file a second level appeal with
Aetna within 60 days of receipt of the level one appeal decision. Aetna will notify you of the decision not later than
15 days (for pre-service claims) or 30 days (for post-service claims) after the appeal is received.
If you do not agree with the Final Internal Adverse Benefit Determination on review, you have the right to bring a
civil action under Section 502(a) of ERISA, if applicable.
Health Claims – Voluntary Appeals
External Review
“External Review” is a review of an eligible Adverse Benefit Determination or a Final Internal Adverse Benefit
Determination by an Independent Review Organization/External Review Organization (ERO) or by the State
Insurance Commissioner, if applicable.
A “Final External Review Decision” is a determination by an ERO at the conclusion of an External Review.
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You must complete all of the levels of standard appeal described above before you can request External Review,
other than in a case of Deemed Exhaustion. Subject to verification procedures that the Plan may establish, your
Authorized Representative may act on your behalf in filing and pursuing this voluntary appeal.
You may file a voluntary appeal for External Review of any Adverse Benefit Determination or any Final Internal
Adverse Benefit Determination that qualifies as set forth below.
The notice of Adverse Benefit Determination or Final Internal Adverse Benefit Determination that you receive from
Aetna will describe the process to follow if you wish to pursue an External Review, and will include a copy of the
Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 123 calendar days of the date you received
the Adverse Benefit Determination or Final Internal Adverse Benefit Determination notice. If the last filing date
would fall on a Saturday, Sunday or Federal holiday, the last filing date is extended to the next day that is not a
Saturday, Sunday or Federal holiday. You also must include a copy of the notice and all other pertinent information
that supports your request.
If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The
filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is
voluntary and you are not required to undertake it before pursuing legal action.
If you choose not to file for voluntary review, the Plan will not assert that you have failed to exhaust your
administrative remedies because of that choice.
Request for External Review
The External Review process under this Plan gives you the opportunity to receive review of an Adverse Benefit
Determination (including a Final Internal Adverse Benefit Determination) conducted pursuant to applicable law.
Your request will be eligible for External Review if the claim decision involves medical judgment and the following
are satisfied:
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Aetna, or the Plan or its designee, does not strictly adhere to all claim determination and appeal requirements
under federal law (except for minor violations); or
the standard levels of appeal have been exhausted; or
the appeal relates to a rescission, defined as a cancellation or discontinuance of coverage which has retroactive
effect.
An Adverse Benefit Determination based upon your eligibility is not eligible for External Review.
If upon the final standard level of appeal, the coverage denial is upheld and it is determined that you are eligible for
External Review, you will be informed in writing of the steps necessary to request an External Review.
An independent review organization refers the case for review by a neutral, independent clinical reviewer with
appropriate expertise in the area in question. The decision of the independent external expert reviewer is binding on
you, Aetna and the Plan unless otherwise allowed by law.
Preliminary Review
Within 5 business days following the date of receipt of the request, Aetna must provide a preliminary review
determining: you were covered under the Plan at the time the service was requested or provided, the determination
does not relate to eligibility, you have exhausted the internal appeals process (unless Deemed Exhaustion applies),
and you have provided all paperwork necessary to complete the External Review and you are eligible for external
review.
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Within one business day after completion of the preliminary review, Aetna must issue to you a notification in
writing. If the request is complete but not eligible for External Review, such notification will include the reasons for
its ineligibility and contact information for the Employee Benefits Security Administration (toll-free number
866-444-EBSA (3272)). If the request is not complete, such notification will describe the information or materials
needed to make the request complete and Aetna must allow you to perfect the request for External Review within
the 123 calendar days filing period or within the 48 hour period following the receipt of the notification, whichever
is later.
Referral to ERO
Aetna will assign an ERO accredited as required under federal law, to conduct the External Review. The assigned
ERO will timely notify you in writing of the request’s eligibility and acceptance for External Review, and will
provide an opportunity for you to submit in writing within 10 business days following the date of receipt, additional
information that the ERO must consider when conducting the External Review. Within one (1) business day after
making the decision, the ERO must notify you, Aetna and the Plan.
The ERO will review all of the information and documents timely received. In reaching a decision, the assigned
ERO will review the claim and not be bound by any decisions or conclusions reached during the Plan’s internal
claims and appeals process. In addition to the documents and information provided, the assigned ERO, to the extent
the information or documents are available and the ERO considers them appropriate, will consider the following in
reaching a decision:
(viii) Your medical records;
(ix) The attending health care professional's recommendation;
(x) Reports from appropriate health care professionals and other documents submitted by the Plan or issuer,
you, or your treating provider;
(xi) The terms of your Plan to ensure that the ERO's decision is not contrary to the terms of the Plan, unless the
terms are inconsistent with applicable law;
(xii)
Appropriate practice guidelines, which must include applicable evidence-based standards and may include
any other practice guidelines developed by the Federal government, national or professional medical societies,
boards, and associations;
(xiii) Any applicable clinical review criteria developed and used by Aetna, unless the criteria are inconsistent
with the terms of the Plan or with applicable law; and
(xiv) The opinion of the ERO's clinical reviewer or reviewers after considering the information described in this
notice to the extent the information or documents are available and the clinical reviewer or reviewers consider
appropriate.
The assigned ERO must provide written notice of the Final External Review Decision within 45 days after the ERO
receives the request for the External Review. The ERO must deliver the notice of Final External Review Decision to
you, Aetna and the Plan.
After a Final External Review Decision, the ERO must maintain records of all claims and notices associated with
the External Review process for six years. An ERO must make such records available for examination by the
claimant, Plan, or State or Federal oversight agency upon request, except where such disclosure would violate State
or Federal privacy laws.
Upon receipt of a notice of a Final External Review Decision reversing the Adverse Benefit Determination or Final
Internal Adverse Benefit Determination, the Plan immediately must provide coverage or payment (including
immediately authorizing or immediately paying benefits) for the claim.
Expedited External Review
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The Plan must allow you to request an expedited External Review at the time you receive:
(c) An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which
the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health or
would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal
appeal; or
(d) A Final Internal Adverse Benefit Determination, if you have a medical condition where the timeframe for
completion of a standard External Review would seriously jeopardize your life or health or would jeopardize
your ability to regain maximum function, or if the Final Internal Adverse Benefit Determination concerns an
admission, availability of care, continued stay, or health care item or service for which you received emergency
services, but have not been discharged from a facility.
Immediately upon receipt of the request for expedited External Review, Aetna will determine whether the request
meets the reviewability requirements set forth above for standard External Review. Aetna must immediately send
you a notice of its eligibility determination.
Referral of Expedited Review to ERO
Upon a determination that a request is eligible for External Review following preliminary review, Aetna will assign
an ERO. The ERO shall render a decision as expeditiously as your medical condition or circumstances require, but
in no event more than 72 hours after the ERO receives the request for an expedited External Review. If the notice is
not in writing, within 48 hours after the date of providing that notice, the assigned ERO must provide written
confirmation of the decision to you, Aetna and the Plan.
Appeal to the Plan
If you choose to appeal to the Plan or its designee following an adverse determination by External Review where
applicable or an adverse determination at the final level of standard appeals, you must do so in writing, and you
should send the following information:
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The specific reason(s) for the appeal;
Copies of all past correspondence with Aetna or the ERO (including any EOBs); and
Any applicable information that you have not yet sent to Aetna and the ERO.
If you file a voluntary appeal, you will be deemed to authorize the Plan or its designee to obtain information from
Aetna relevant to your claim.
Mail your written appeal directly to:
10202 West Washington Blvd.
The Plan or its designee will review your appeal. The reviewer will evaluate your claim within 60 days after you file
your appeal and make a decision. If the reviewer needs more time, the reviewer may take an additional 60-day
period. The reviewer will notify you in advance of this extension. The reviewer will follow relevant internal rules
maintained by Aetna to the extent they do not conflict with the Plan’s own internal guidelines.
The reviewer will notify you of the final decision on your appeal electronically or in writing. The written notice will
give you the reason for the decision and what Plan provisions apply.
All decisions by the Plan or its designee with respect to your claim shall be final and binding.
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Glossary
In this section, you will find definitions for the words and phrases that appear in bold type throughout the text of
Accident
This means a sudden; unexpected; and unforeseen; identifiable occurrence or event producing, at the time,
objective symptoms of a bodily injury. The accident must occur while the person is covered under this Contract.
The occurrence or event must be definite as to time and place. It must not be due to, or contributed by, an illness or
disease of any kind.
Aetna
Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna.
Ambulance
A vehicle that is staffed with medical personnel and equipped to transport an ill or injured person.
Average Wholesale Price (AWP)
The current average wholesale price of a prescription drug listed in the Facts and Comparisons weekly price
updates (or any other similar publication designated by Aetna) on the day that a pharmacy claim is submitted for
adjudication.
Behavioral Health Provider/Practitioner
A licensed organization or professional providing diagnostic, therapeutic or psychological services for behavioral
health conditions.
Birthing Center
A freestanding facility that meets all of the following requirements:
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Meets licensing standards.
Is set up, equipped and run to provide prenatal care, delivery and immediate postpartum care.
Charges for its services.
Is directed by at least one physician who is a specialist in obstetrics and gynecology.
Has a physician or certified nurse midwife present at all births and during the immediate postpartum period.
Extends staff privileges to physicians who practice obstetrics and gynecology in an area hospital.
Has at least 2 beds or 2 birthing rooms for use by patients while in labor and during delivery.
Provides, during labor, delivery and the immediate postpartum period, full-time skilled nursing services
directed by an R.N. or certified nurse midwife.
Provides, or arranges with a facility in the area for, diagnostic X-ray and lab services for the mother and child.
Has the capacity to administer a local anesthetic and to perform minor surgery. This includes episiotomy and
repair of perineal tear.
Is equipped and has trained staff to handle emergency medical conditions and provide immediate support
measures to sustain life if:
 Complications arise during labor; or
 A child is born with an abnormality which impairs function or threatens life.
Accepts only patients with low-risk pregnancies.
Has a written agreement with a hospital in the area for emergency transfer of a patient or a child. Written
procedures for such a transfer must be displayed and the staff must be aware of them.
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Provides an ongoing quality assurance program. This includes reviews by physicians who do not own or direct
the facility.
Keeps a medical record on each patient and child.
Body Mass Index
This is a practical marker that is used to assess the degree of obesity and is calculated by dividing the weight in
kilograms by the height in meters squared.
Brand-Name Prescription Drug
A prescription drug with a proprietary name assigned to it by the manufacturer or distributor and so indicated by
Medi-Span or any other similar publication designated by Aetna or an affiliate.
Copay or Copayment
The specific dollar amount or percentage required to be paid by you or on your behalf. The plan includes various
copayments, and these copayment amounts or percentages are specified in the Schedule of Benefits.
Cosmetic
Services or supplies that alter, improve or enhance appearance.
Covered Expenses
Medical, dental, vision or hearing services and supplies shown as covered under this Benefit Description.
Creditable Coverage
A person’s prior medical coverage as defined in the Health Insurance Portability and Accountability Act of 1996
(HIPAA).
Such coverage includes:
 Health coverage issued on a group or individual basis;
 Medicare;
 Medicaid;
 Health care for members of the uniformed services;
 A program of the Indian Health Service;
 A state health benefits risk pool;
 The Federal Employees’ Health Benefit Plan (FEHBP);
 A public health plan (any plan established by a State, the government of the United States, or any subdivision of
a State or of the government of the United States, or a foreign country);
 Any health benefit plan under Section 5(e) of the Peace Corps Act; and
 The State Children’s Health Insurance Program (S-Chip).
Custodial Care
Services and supplies that are primarily intended to help you meet personal needs. Custodial care can be prescribed
by a physician or given by trained medical personnel. It may involve artificial methods such as feeding tubes,
ventilators or catheters. Examples of custodial care include:
 Routine patient care such as changing dressings, periodic turning and positioning in bed, administering
medications;
 Care of a stable tracheostomy (including intermittent suctioning);
 Care of a stable colostomy/ileostomy;
 Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings;
 Care of a stable indwelling bladder catheter (including emptying/changing containers and clamping tubing);
 Watching or protecting you;
 Respite care, adult (or child) day care, or convalescent care;
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Institutional care, including room and board for rest cures, adult day care and convalescent care;
Help with the daily living activities, such as walking, grooming, bathing, dressing, getting in or out of bed,
toileting, eating or preparing foods;
Any services that a person without medical or paramedical training could be trained to perform; and
Any service that can be performed by a person without any medical or paramedical training.
Day Care Treatment
A partial confinement treatment program to provide treatment for you during the day. The hospital, psychiatric
hospital or residential treatment facility does not make a room charge for day care treatment. Such treatment
must be available for at least 4 hours, but not more than 12 hours in any 24-hour period.
Deductible
The part of your covered expenses you pay before the plan starts to pay benefits. Additional information regarding
deductibles and deductible amounts can be found in the Schedule of Benefits.
Dentist
A legally qualified dentist, or a physician licensed to do the dental work he or she performs.
Detoxification
The process by which an alcohol-intoxicated or drug-intoxicated; or an alcohol-dependent or drug-dependent
person is medically managed through the period of time necessary to eliminate, by metabolic or other means, the:
 Intoxicating alcohol or drug;
 Alcohol or drug-dependent factors; or
 Alcohol in combination with drugs;
as determined by a physician. The process must keep the physiological risk to the patient at a minimum, and take
place in a facility that meets any applicable licensing standards established by the jurisdiction in which it is located.
Directory
A listing of all network providers serving the class of employees to which you belong. The contractholder will
give you a copy of this directory. Network provider information is also available through Aetna's online provider
directory, DocFind®.
Equipment, and the accessories needed to operate it, that is:
 Made to withstand prolonged use;
 Made for and mainly used in the treatment of an illness or injury;
 Suited for use in the home;
 Not normally of use to people who do not have an illness or injury;
 Not for use in altering air quality or temperature; and
 Not for exercise or training.
Durable medical and surgical equipment does not include equipment such as whirlpools, portable whirlpool
pumps, sauna baths, massage devices, over bed tables, elevators, communication aids, vision aids and telephone
alert systems.
Emergency Care
This means the treatment given in a hospital's emergency room to evaluate and treat an emergency medical
condition.
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Emergency Medical Condition
A recent and severe medical condition, including (but not limited to) severe pain, which would lead a prudent
layperson possessing an average knowledge of medicine and health, to believe that his or her condition, illness, or
injury is of such a nature that failure to get immediate medical care could result in:
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Placing your health in serious jeopardy; or
Serious impairment to bodily function; or
Serious dysfunction of a body part or organ; or
In the case of a pregnant woman, serious jeopardy to the health of the fetus.
Experimental or Investigational
Except as provided for under the Clinical Trials benefit provision, a drug, a device, a procedure, or treatment will be
determined to be experimental or investigational if:
 There is not enough outcomes data available from controlled clinical trials published in the peer-reviewed
literature to substantiate its safety and effectiveness for the illness or injury involved; or
 Approval required by the FDA has not been granted for marketing; or
 A recognized national medical or dental society or regulatory agency has determined, in writing, that it is
experimental or investigational, or for research purposes; or
 It is a type of drug, device or treatment that is the subject of a Phase I or Phase II clinical trial or the
experimental or research arm of a Phase III clinical trial, using the definition of “phases” indicated in
regulations and other official actions and publications of the FDA and Department of Health and Human
Services; or
 The written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility
studying substantially the same:
 drug;
 device;
 procedure; or
 treatment.
It also includes the written informed consent used by:
 the treating facility; or
 by another facility studying the same:
 drug;
 device;
 procedure; or
 treatment.
that states that it is experimental or investigational, or for research purposes.
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Generic Prescription Drug
A prescription drug, that is identified by its:
 chemical;
 proprietary; or
 non-proprietary name; and
 is accepted by the U.S. Food and Drug Administration as therapeutically the same; and
 can be replaced with drugs with the same amount of active ingredient; and
 so stated by Medispan or any other publication named by Aetna or consort.
Homebound
This means that you are confined to your place of residence:
 Due to an illness or injury which makes leaving the home medically contraindicated; or
 Because the act of transport would be a serious risk to your life or health.
Situations where you would not be considered homebound include (but are not limited to) the following:
 You do not often travel from home because of feebleness or insecurity brought on by advanced age (or
otherwise); or
 You are wheelchair bound but could safely be transported via wheelchair accessible transportation.
Home Health Care Agency
An agency that meets all of the following requirements.
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Mainly provides skilled nursing and other therapeutic services.
Is associated with a professional group (of at least one physician and one R.N.) which makes policy.
Has full-time supervision by a physician or an R.N.
Keeps complete medical records on each person.
Has an administrator.
Home Health Care Plan
This is a plan that provides for continued care and treatment of an illness or injury. The care and treatment must be:
 Prescribed in writing by the attending physician; and
 An alternative to a hospital or skilled nursing facility stay.
Hospice Care
This is care given to a terminally ill person by or under arrangements with a hospice care agency. The care must be
part of a hospice care program.
Hospice Care Agency
An agency or organization that meets all of the following requirements:
 Has hospice care available 24 hours a day.
 Meets any licensing or certification standards established by the jurisdiction where it is located.
 Provides:
 Skilled nursing services;
 Medical social services; and
 Psychological and dietary counseling.
 Provides, or arranges for, other services which include:
 Physician services;
 Part-time home health aide services which mainly consist of caring for terminally ill people; and
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 Inpatient care in a facility when needed for pain control and acute and chronic symptom management.
Has at least the following personnel:
 One physician;
 One R.N.; and
 One licensed or certified social worker employed by the agency.
Establishes policies about how hospice care is provided.
Assesses the patient's medical and social needs.
Develops a hospice care program to meet those needs.
Provides an ongoing quality assurance program. This includes reviews by physicians, other than those who
own or direct the agency.
Permits all area medical personnel to utilize its services for their patients.
Keeps a medical record on each patient.
Uses volunteers trained in providing services for non-medical needs.
Has a full-time administrator.
Hospice Care Program
This is a written plan of hospice care, which:
 Is established by and reviewed from time to time by a physician attending the person, and appropriate
personnel of a hospice care agency;
 Is designed to provide palliative and supportive care to terminally ill persons, and supportive care to their
families; and
 Includes an assessment of the person's medical and social needs; and a description of the care to be given to
meet those needs.
Hospice Facility
A facility, or distinct part of one, that meets all of the following requirements:
 Mainly provides inpatient hospice care to terminally ill persons.
 Charges patients for its services.
 Meets any licensing or certification standards established by the jurisdiction where it is located.
 Keeps a medical record on each patient.
 Provides an ongoing quality assurance program including reviews by physicians other than those who own or
direct the facility.
 Is run by a staff of physicians. At least one staff physician must be on call at all times.
 Provides 24-hour-a-day nursing services under the direction of an R.N.
 Has a full-time administrator.
Hospital
An institution that:
 Is primarily engaged in providing, on its premises, inpatient medical, surgical and diagnostic services;
 Is supervised by a staff of physicians;
 Provides twenty-four (24) hour-a-day R.N. service,
 Charges patients for its services;
 Is operating in accordance with the laws of the jurisdiction in which it is located; and
 Does not meet all of the requirements above, but does meet the requirements of the jurisdiction in which it
operates for licensing as a hospital and is accredited as a hospital by the Joint Commission on the Accreditation
of Healthcare Organizations.
In no event does hospital include a convalescent nursing home or any institution or part of one which is used
principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care facility,
intermediate care facility, skilled nursing facility, hospice, rehabilitative hospital or facility primarily for
rehabilitative or custodial services.
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Hospitalization
A continuous confinement as an inpatient in a hospital for which a room and board charge is made.
Illness
A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings
peculiar to the findings set the condition apart as an abnormal entity differing from other normal or pathological
body states.
Infertile or Infertility
The condition of a presumably healthy covered person who is unable to conceive or produce conception after:
 For a woman who is under 35 years of age: 1 year or more of timed, unprotected coitus, or 12 cycles of artificial
insemination; or
 For a woman who is 35 years of age or older: 6 months or more of timed, unprotected coitus, or 6 cycles of
artificial insemination.
Injury
An accidental bodily injury that is the sole and direct result of:
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An unexpected or reasonably unforeseen occurrence or event; or
The reasonable unforeseeable consequences of a voluntary act by the person.
An act or event must be definite as to time and place.
Institute of Excellence (IOE)
A hospital or other facility that has contracted with Aetna to give services or supplies to an IOE patient in
connection with specific transplants, procedures at a negotiated charge. A facility is an IOE facility only for those
types of transplants, procedures for which it has signed a contract.
Jaw Joint Disorder
This is:
 A Temporomandibular Joint (TMJ) dysfunction or any alike disorder of the jaw joint; or
 A Myofacial Pain Dysfunction (MPD); or
 Any alike disorder in the relationship of the jaw joint and the related muscles and nerves.
Late Enrollee
This is an employee in an Eligible Class who requests enrollment under this Plan after the Initial Enrollment Period.
In addition, this is an eligible dependent for whom the employee did not elect coverage within the Initial Enrollment
Period, but for whom coverage is elected at a later time.
However, an eligible employee or dependent may not be considered a Late Enrollee under certain circumstances.
See the Special Enrollment Periods section of the Benefit Description.
L.P.N.
A licensed practical or vocational nurse.
Mail Order Pharmacy
An establishment where prescription drugs are legally given out by mail or other carrier.
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Maintenance Care
Care made up of services and supplies that:
 Are given mainly to maintain, rather than to improve, a level of physical, or mental function; and
 Give a surrounding free from exposures that can worsen the person's physical or mental condition.
Your plan has a maximum out-of-pocket limit. Your deductibles, payment percentage, copays and other
eligible out-of-pocket expense apply to the maximum out-of-pocket limit. Once you satisfy the maximum amount
the plan will pay 100% of covered expenses that apply toward the limit for the rest of the calendar year.
Medically Necessary or Medical Necessity
These are health care or dental services, and supplies or prescription drugs that a physician, other health care
provider or dental provider, exercising prudent clinical judgment, would give to a patient for the purpose of:
 preventing;
 evaluating;
 diagnosing; or
 treating:
 an illness;
 an injury;
 a disease; or
 its symptoms.
The provision of the service, supply or prescription drug must be:
a) In accordance with generally accepted standards of medical or dental practice;
b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the
patient's illness, injury or disease; and
c) Not mostly for the convenience of the patient, physician, other health care or dental provider; and
d) And do not cost more than an alternative service or sequence of services at least as likely to produce the same
therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.
For these purposes “generally accepted standards of medical or dental practice” means standards that are based on
credible scientific evidence published in peer-reviewed literature. They must be generally recognized by the
relevant medical or dental community. Otherwise, the standards are consistent with physician or dental specialty
society recommendations. They must be consistent with the views of physicians or dentists practicing in relevant
clinical areas and any other relevant factors.
Mental Disorder
An illness commonly understood to be a mental disorder, whether or not it has a physiological basis, and for which
treatment is generally provided by or under the direction of a behavioral health provider such as a psychiatric
physician, a psychologist or a psychiatric social worker.
Any one of the following conditions is a mental disorder under this plan:
 Anorexia/Bulimia Nervosa.
 Bipolar disorder.
 Major depressive disorder.
 Obsessive compulsive disorder.
 Panic disorder.
 Pervasive developmental disorder (including Autism).
 Psychotic disorders/Delusional disorder.
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Schizo-affective disorder.
Schizophrenia.
Also included is any other mental condition which requires Medically Necessary treatment.
Morbid Obesity
This means a Body Mass Index that is: greater than 40 kilograms per meter squared; or equal to or greater than 35
kilograms per meter squared with a comorbid medical condition, including: hypertension; a cardiopulmonary
condition; sleep apnea; or diabetes.
Negotiated Charge
The maximum charge a network provider has agreed to make as to any service or supply for the purpose of the
benefits under this plan.
Network Advanced Reproductive Technology (ART) Specialist
A specialist physician who has entered into a contractual agreement with Aetna for the provision of covered
Advanced Reproductive Technology (ART) services.
Network Provider
A health care provider who has contracted to furnish services or supplies for this plan; but only if the provider is,
with Aetna's consent, included in the directory as a network provider for:
 The service or supply involved; and
 The class of employees to which you belong.
Network Service(s) or Supply(ies)
Health care service or supply that is:
 Furnished by a network provider; or
 Furnished or arranged by your PCP.
Night Care Treatment
A partial confinement treatment program provided when you need to be confined during the night. A room
charge is made by the hospital, psychiatric hospital or residential treatment facility. Such treatment must be
available at least:
 8 hours in a row a night; and
 5 nights a week.
Non-Occupational Illness
A non-occupational illness is an illness that does not:
 Arise out of (or in the course of) any work for pay or profit; or
 Result in any way from an illness that does.
An illness will be deemed to be non-occupational regardless of cause if proof is furnished that the person:
 Is covered under any type of workers' compensation law; and
 Is not covered for that illness under such law.
Non-Occupational Injury
A non-occupational injury is an accidental bodily injury that does not:
 Result in any way from an injury which does.
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Non-Specialist
A physician who is not a specialist.
Non-Urgent Admission
An inpatient admission that is not an emergency admission or an urgent admission.
Occupational Injury or Occupational Illness
An injury or illness that:
 Arises out of (or in the course of) any activity in connection with employment or self-employment whether or
not on a full time basis; or
 Results in any way from an injury or illness that does.
Occurrence
This means a period of disease or injury. An occurrence ends when 60 consecutive days have passed during which
the covered person:
 Receives no medical treatment; services; or supplies; for a disease or injury; and
 Neither takes any medication, nor has any medication prescribed, for a disease or injury.
Orthodontic Treatment
This is any:
 Medical service or supply; or
 Dental service or supply;
furnished to prevent or to diagnose or to correct a misalignment:
 Of the teeth; or
 Of the bite; or
 Of the jaws or jaw joint relationship;
whether or not for the purpose of relieving pain.
The following are not considered orthodontic treatment:
 The installation of a space maintainer; or
 A surgical procedure to correct malocclusion.
Out-of-Network Provider
A health care provider who has not contracted with Aetna, an affiliate, or a third party vendor, to furnish services or
supplies for this plan.
A plan of medical, psychiatric, nursing, counseling, or therapeutic services to treat substance abuse or mental
disorders. The plan must meet these tests:
 It is carried out in a hospital; psychiatric hospital or residential treatment facility; on less than a full-time
inpatient basis.
 It is in accord with accepted medical practice for the condition of the person.
 It does not require full-time confinement.
 It is supervised by a psychiatric physician who weekly reviews and evaluates its effect.
 Day care treatment and night care treatment are considered partial confinement treatment.
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Payment Percentage
Payment percentage is both the percentage of covered expenses that the plan pays, and the percentage of covered
expenses that you pay. The percentage that the plan pays is referred to as the “plan payment percentage,” and
varies by the type of expense. Please refer to the Schedule of Benefits for specific information on payment
percentage amounts.
Pharmacy
An establishment where prescription drugs are legally dispensed. Pharmacy includes a retail pharmacy, mail
order pharmacy and specialty pharmacy network pharmacy.
Physician
A duly licensed member of a medical profession who:
 Has an M.D. or D.O. degree;
 Is properly licensed or certified to provide medical care under the laws of the jurisdiction where the individual
practices; and
 Provides medical services which are within the scope of his or her license or certificate.
This also includes a health professional who:
 Is properly licensed or certified to provide medical care under the laws of the jurisdiction where he or she
practices;
 Provides medical services which are within the scope of his or her license or certificate;
 Under applicable insurance law is considered a "physician" for purposes of this coverage;
 Has the medical training and clinical expertise suitable to treat your condition;
 Specializes in psychiatry, if your illness or injury is caused, to any extent, by alcohol abuse, substance abuse or
a mental disorder; and
 A physician is not you or related to you.
Precertification or Precertify
A process where Aetna is contacted before certain services are provided, such as hospitalization or outpatient
surgery, or prescription drugs are prescribed to determine whether the services being recommended or the drugs
prescribed are considered covered expenses under the plan. It is not a guarantee that benefits will be payable.
Prescriber
Any physician or dentist, acting within the scope of his or her license, who has the legal authority to write an order
for a prescription drug.
Prescription
An order for the dispensing of a prescription drug by a prescriber. If it is an oral order, it must be promptly put in
writing by the pharmacy.
Prescription Drug
A drug, biological, or compounded prescription which, by State and Federal Law, may be dispensed only by
prescription and which is required to be labeled "Caution: Federal Law prohibits dispensing without prescription."
This includes:
 An injectable drug prescribed to be self-administered or administered by any other person except one who is
acting within his or her capacity as a paid healthcare professional. Covered injectable drugs include injectable
insulin.
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Primary Care Physician (PCP)
This is the network provider who:
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Is selected by a person from the list of primary care physicians in the directory;
Supervises, coordinates and provides initial care and basic medical services to a person as a general or family
care practitioner, or in some cases, as an internist or a pediatrician; and
Is shown on Aetna's records as the person's PCP.
Psychiatric Hospital
This is an institution that meets all of the following requirements.
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Mainly provides a program for the diagnosis, evaluation, and treatment of alcoholism, substance abuse or
mental disorders.
Is not mainly a school or a custodial, recreational or training institution.
Provides infirmary-level medical services. Also, it provides, or arranges with a hospital in the area for, any
other medical service that may be required.
Is supervised full-time by a psychiatric physician who is responsible for patient care and is there regularly.
Is staffed by psychiatric physicians involved in care and treatment.
Has a psychiatric physician present during the whole treatment day.
Provides, at all times, psychiatric social work and nursing services.
Provides, at all times, skilled nursing services by licensed nurses who are supervised by a full-time R.N.
Prepares and maintains a written plan of treatment for each patient based on medical, psychological and social
needs. The plan must be supervised by a psychiatric physician.
Makes charges.
Psychiatric Physician
This is a physician who:
 Specializes in psychiatry; or
 Has the training or experience to do the required evaluation and treatment of alcoholism, substance abuse or
mental disorders.
Recognized Charge
The covered expense is only that part of a charge which is the recognized charge.
As to medical, vision and hearing expenses, the recognized charge for each service or supply is the lesser of:
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What the provider bills or submits for that service or supply; and
For professional services and other services or supplies not mentioned below:
 the 80th percentile of the Prevailing Charge Rate;
for the Geographic Area where the service is furnished.
If Aetna has an agreement with a provider (directly, or indirectly through a third party) which sets the rate that
Aetna will pay for a service or supply, then the recognized charge is the rate established in such agreement.
Aetna may also reduce the recognized charge by applying Aetna Reimbursement Policies. Aetna Reimbursement
Policies address the appropriate billing of services, taking into account factors that are relevant to the cost of the
service such as:
 the duration and complexity of a service;
 whether multiple procedures are billed at the same time, but no additional overhead is required;
 whether an assistant surgeon is involved and necessary for the service;
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if follow up care is included;
whether there are any other characteristics that may modify or make a particular service unique; and
when a charge includes more than one claim line, whether any services described by a claim line are part of or
incidental to the primary service provided.
Aetna Reimbursement Policies are based on Aetna's review of: the policies developed for Medicare; the generally
accepted standards of medical and dental practice, which are based on credible scientific evidence published in
peer-reviewed literature generally recognized by the relevant medical or dental community or which is otherwise
consistent with physician or dental specialty society recommendations; and the views of physicians and dentists
practicing in the relevant clinical areas. Aetna uses a commercial software package to administer some of these
policies.
As used above, Geographic Area and Prevailing Charge Rates are defined as follows:
 Geographic Area: This means an expense area grouping defined by the first three digits of the U.S. Postal
Service zip codes. If the volume of charges in a single three digit zip code is sufficient to produce a statistically
valid sample, an expense area is made up of a single three digit zip code. If the volume of charges is not
sufficient to produce a statistically valid sample, two or more three digit zip codes are grouped to produce a
statistically valid sample. When it is necessary to group three digit zip codes, the grouping never crosses state
lines.
 Prevailing Charge Rates: These are rates reported by FAIR Health, a nonprofit company, in their database.
FAIR Health reviews and, if necessary, changes these rates periodically. Aetna updates its systems with these
changes within 180 days after receiving them from FAIR Health.
Important Note
Aetna periodically updates its systems with changes made to the Prevailing Charge Rates.
What this means to you is that the recognized charge is based on the version of the rates that is in use by Aetna on
the date that the service or supply was provided.
Additional Information
Aetna's website aetna.com may contain additional information which may help you determine the cost of a service
or supply. Log on to Aetna Navigator to access the "Estimate the Cost of Care" feature. Within this feature, view
our "Cost of Care" and "Member Payment Estimator" tools, or contact our Customer Service Department for
assistance.
Rehabilitation Facility
A facility, or a distinct part of a facility which provides rehabilitative services, meets any licensing or certification
standards established by the jurisdiction where it is located, and makes charges for its services.
Rehabilitative Services
The combined and coordinated use of medical, social, educational and vocational measures for training or retraining
if you are disabled by illness or injury.
Residential Treatment Facility (Mental Disorders)
This is an institution that meets all of the following requirements:
 On-site licensed Behavioral Health Provider 24 hours per day/7 days a week.
 Provides a comprehensive patient assessment (preferably before admission, but at least upon admission).
 Is admitted by a Physician.
 Has access to necessary medical services 24 hours per day/7 days a week.
 Provides living arrangements that foster community living and peer interaction that are consistent with
developmental needs.
 Offers group therapy sessions with at least an RN or Masters-Level Health Professional.
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Has the ability to involve family/support systems in therapy (required for children and adolescents; encouraged
for adults).
Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual psychotherapy.
Has peer oriented activities.
Services are managed by a licensed Behavioral Health Provider who, while not needing to be individually
contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2) function
under the direction/supervision of a licensed psychiatrist (Medical Director).
Has individualized active treatment plan directed toward the alleviation of the impairment that caused the
admission.
Provides a level of skilled intervention consistent with patient risk.
Meets any and all applicable licensing standards established by the jurisdiction in which it is located.
Is not a Wilderness Treatment Program or any such related or similar program, school and/or education service.
Residential Treatment Facility (Substance Abuse)
This is an institution that meets all of the following requirements:
 On-site licensed Behavioral Health Provider 24 hours per day/7 days a week.
 Provides a comprehensive patient assessment (preferably before admission, but at least upon admission).
 Is admitted by a Physician.
 Has access to necessary medical services 24 hours per day/7 days a week.
 If the member requires detoxification services, must have the availability of on-site medical treatment 24 hours
per day/7days a week, which must be actively supervised by an attending Physician.
 Provides living arrangements that foster community living and peer interaction that are consistent with
developmental needs.
 Offers group therapy sessions with at least an RN or Masters-Level Health Professional.
 Has the ability to involve family/support systems in therapy (required for children and adolescents; encouraged
for adults).
 Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual psychotherapy.
 Has peer oriented activities.
 Services are managed by a licensed Behavioral Health Provider who, while not needing to be individually
contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2) function
under the direction/supervision of a licensed psychiatrist (Medical Director).
 Has individualized active treatment plan directed toward the alleviation of the impairment that caused the
admission.
 Provides a level of skilled intervention consistent with patient risk.
 Meets any and all applicable licensing standards established by the jurisdiction in which it is located.
 Is not a Wilderness Treatment Program or any such related or similar program, school and/or education service.
 Ability to assess and recognize withdrawal complications that threaten life or bodily functions and to obtain
needed services either on site or externally.
 24-hours per day/7 days a week supervision by a physician with evidence of close and frequent observation.
 On-site, licensed Behavioral Health Provider, medical or substance abuse professionals 24 hours per day/7
days a week.
R.N.
A registered nurse.
Room and Board
Charges made by an institution for room and board and other medically necessary services and supplies. The
charges must be regularly made at a daily or weekly rate.
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Semi-Private Room Rate
The room and board charge that an institution applies to the most beds in its semi-private rooms with 2 or more
beds. If there are no such rooms, Aetna will figure the rate based on the rate most commonly charged by similar
institutions in the same geographic area.
Service Area
This is the geographic area, as determined by Aetna, in which network providers for this plan are located.
An institution that meets all of the following requirements:
 It is licensed to provide, and does provide, the following on an inpatient basis for persons convalescing from
illness or injury:
 Professional nursing care by an R.N., or by a L.P.N. directed by a full-time R.N.; and
 Physical restoration services to help patients to meet a goal of self-care in daily living activities.
 Provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N.
 Is supervised full-time by a physician or an R.N.
 Keeps a complete medical record on each patient.
 Has a utilization review plan.
 Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for mental retardates, for custodial or
educational care, or for care of mental disorders.
 Charges patients for its services.
 An institution or a distinct part of an institution that meets all of the following requirements:
 It is licensed or approved under state or local law.
 Is primarily engaged in providing skilled nursing care and related services for residents who require
medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.
 Qualifies as a skilled nursing facility under Medicare or as an institution accredited by:
 The Joint Commission on Accreditation of Health Care Organizations;
 The Bureau of Hospitals of the American Osteopathic Association; or
 The Commission on the Accreditation of Rehabilitative Facilities
Skilled nursing facilities also include rehabilitation hospitals (all levels of care, e.g. acute) and portions of a
hospital designated for skilled or rehabilitation services.
Skilled nursing facility does not include:
 Institutions which provide only:
 Minimal care;
 Custodial care services;
 Ambulatory; or
 Part-time care services.
 Institutions which primarily provide for the care and treatment of alcoholism, substance abuse or mental
disorders.
Skilled Nursing Services
Services that meet all of the following requirements:
 The services require medical or paramedical training.
 The services are rendered by an R.N. or L.P.N. within the scope of his or her license.
 The services are not custodial.
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Specialist
A physician who practices in any generally accepted medical or surgical sub-specialty.
Specialty Care
Health care services or supplies that require the services of a specialist.
Stay
A full-time inpatient confinement for which a room and board charge is made.
Substance Abuse
This is a physical or psychological dependency, or both, on a controlled substance or alcohol agent (These are
defined on Axis I in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American
Psychiatric Association which is current as of the date services are rendered to you or your covered dependents.)
This term does not include conditions not attributable to a mental disorder that are a focus of attention or treatment
(the V codes on Axis I of DSM); an addiction to nicotine products, food or caffeine intoxication.
Surgery Center
A freestanding ambulatory surgical facility that meets all of the following requirements:
 Meets licensing standards.
 Is set up, equipped and run to provide general surgery.
 Charges for its services.
 Is directed by a staff of physicians. At least one of them must be on the premises when surgery is performed and
during the recovery period.
 Has at least one certified anesthesiologist at the site when surgery requiring general or spinal anesthesia is
performed and during the recovery period.
 Extends surgical staff privileges to:
 Physicians who practice surgery in an area hospital; and
 Dentists who perform oral surgery.
 Has at least 2 operating rooms and one recovery room.
 Provides, or arranges with a medical facility in the area for, diagnostic x-ray and lab services needed in
connection with surgery.
 Does not have a place for patients to stay overnight.
 Provides, in the operating and recovery rooms, full-time skilled nursing services directed by an R.N.
 Is equipped and has trained staff to handle emergency medical conditions.
Must have all of the following:
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A physician trained in cardiopulmonary resuscitation; and
A defibrillator; and
A tracheotomy set; and
A blood volume expander.
Has a written agreement with a hospital in the area for immediate emergency transfer of patients.
Written procedures for such a transfer must be displayed and the staff must be aware of them.
Provides an ongoing quality assurance program. The program must include reviews by physicians who do not
own or direct the facility.
Keeps a medical record on each patient.
Terminally Ill (Hospice Care)
Terminally ill means a medical prognosis of 12 months or less to live.
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Urgent Admission
A hospital admission by a physician due to:
 The onset of or change in an illness; or
 The diagnosis of an illness; or
 An injury.
 The condition, while not needing an emergency admission, is severe enough to require confinement as an
inpatient in a hospital within 2 weeks from the date the need for the confinement becomes apparent.
Urgent Care Provider
This is:
 A freestanding medical facility that meets all of the following requirements.
 Provides unscheduled medical services to treat an urgent condition if the person’s physician is not
reasonably available.
 Routinely provides ongoing unscheduled medical services for more than 8 consecutive hours.
 Makes charges.
 Is licensed and certified as required by any state or federal law or regulation.
 Keeps a medical record on each patient.
 Provides an ongoing quality assurance program. This includes reviews by physicians other than those who
own or direct the facility.
 Is run by a staff of physicians. At least one physician must be on call at all times.
 Has a full-time administrator who is a licensed physician.
 A physician’s office, but only one that:
 Has contracted with Aetna to provide urgent care; and
 Is, with Aetna’s consent, included in the directory as a network urgent care provider.
It is not the emergency room or outpatient department of a hospital.
Urgent Condition
This means a sudden illness; injury; or condition; that:
 Is severe enough to require prompt medical attention to avoid serious deterioration of your health;
 Includes a condition which would subject you to severe pain that could not be adequately managed without
urgent care or treatment;
 Does not require the level of care provided in the emergency room of a hospital; and
 Requires immediate outpatient medical care that cannot be postponed until your physician becomes reasonably
available.
Walk-in Clinic
Walk-in Clinics are free-standing health care facilities. They are an alternative to a physician’s office visit for
treatment of:
 The administration of certain immunizations; and
 Individual screening and counseling services.
It is not an alternative for emergency room services or the ongoing care provided by a physician.
Neither:
 An emergency room; nor
 The outpatient department of a hospital;
shall be considered a Walk-in Clinic.
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B.2 MEDICAL – KAISER HMO
How an HMO Works
A Health Maintenance Organization (HMO) provides services through a select group of doctors, hospitals,
and other providers who are under contract to the HMO.
If you live or work within the plan’s service area, as defined by your zip code, you’re eligible to join that
HMO. For most HMOs, you need to choose a primary care physician (PCP) or facility from a list of
providers in the service area when you enroll.
If you receive medical services outside your PCP’s office without being referred by your PCP, you usually
won’t receive any benefits coverage (with exceptions for emergencies). Contact the HMO directly and/or
access its Web site for participating provider network information and to ask any questions about the
benefits it may provide for out-of-network services, including emergency care.
Your HMO Option
The plan summaries included in the Plan Information section of Your Benefits Resources are not
all-inclusive.
Contact the plan’s member services to request additional detail at no cost to you.
SPE currently offers:
Kaiser Permanente HMOs—Offered to Southern California employees only
For Dependents Not Living With You
If you have a covered dependent who doesn’t live with you but does live in the HMO service area, he or
she should choose a PCP and have that PCP coordinate all care.
If your covered dependent lives outside the HMO service area, call the HMO directly to find out what
benefits, if any, are available.
If You’re Traveling
If you need medical care while traveling outside the network service area:
 Contact your PCP or HMO as soon as possible after you receive emergency care.
 Contact your HMO before you receive any nonemergency care.
Kaiser Permanente HMO
If you live in Southern California, you may be offered a Kaiser Permanente HMO option, depending on
whether you live or work in the HMO’s service area.
Coverage Summary
Here’s an overview of what you pay and what the plan pays for covered medical services. In general the
plan pays 100% after any applicable co-payment (there’s no annual deductible).
Plan Feature Coverage
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Plan Feature
Primary Care Physician Office
Visit
Specialist Office Visit
Coverage
The plan pays 100% after you pay a $20
co-payment per visit
co-payment per visit
Out-of-Pocket Maximum
$1,500 per individual, $3,000 per family
Hospitalization
The plan pays 100% after $100 co-payment
Emergency care in a hospital
co-payment (co-payment waived if
admitted to hospital)
Out-patient facility providing
surgical care
co-payment
Out-patient laboratory services
The plan pays 100%
Prescription drugs
The plan pays 100% after you pay a co-payment
per prescription
Retail participating pharmacy
(up to a 100-day supply for maintenance
medications)
Generic: $10
Brand: $20 (formulary and non-formulary)*
Mail order (up to a 100-day supply for
maintenance medications)
Generic: $20 (refills only)
Brand (formulary and non-formulary): $40*
*Must be medically necessary, prescribed by a plan physician, and obtained at plan pharmacies to be
covered.
Covered Services
The following is a general summary of medical care that is covered when medically necessary treatment is
provided for an illness or injury. Services must be performed or prescribed by your PCP, or when required,
authorized by your PCP and performed by another participating provider.
In general for any of the following services, coverage is 100% after any applicable co-payment as
described in the Coverage Summary.
 Medical treatment by a physician, surgeon, or other covered practitioner;
 Medical care and treatment furnished by a hospital;
 In-patient hospital services as well as room and board in a semiprivate room for general illness,
accidental injury, surgery, maternity, and newborn;
 Anesthesia and charges for administering it;
 Diagnostic X-rays and diagnostic laboratory services;
 Preadmission testing performed in the out-patient department of the hospital before
hospitalization;
 Emergency room treatment at a nonparticipating facility (must be certified by the plan within
forty-eight hours after treatment is received);
 Allergy testing and treatment;
 Reconstructive surgery following a mastectomy;
 Injections;
 Immunizations (if administered during a covered preventive care visit);
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Oxygen and rental of durable medical equipment;
X-ray, radium, and radioactive isotope therapies;
Blood transfusions, including the cost of whole blood or blood plasma;
Local transportation to or from the hospital by a professional ambulance service;
Casts, splints, crutches, trusses, and braces;
Artificial limbs and eyes required because of loss while covered; and
Treatment by a physical therapist if prescribed by your PCP.
This list is not all-inclusive so it’s important to contact the plan directly if you have questions about
coverage for specific services.
Special Coverage Rules
Special coverage rules apply for certain expenses as described below.
Preventive Care
The following preventive care services are covered 100%.
 Annual adult physical exam
 Annual well-woman exam, including Pap test with PCP or participating gynecologist; Pap test
included when physician ordered
 Pediatric exams: no co-payment to age 23 months; $25 co-payment thereafter;
 Pediatric immunizations;
 Mammogram;
 Oral contraceptives on both a retail and mail-order basis if FDA approved and prescribed by a
Kaiser Permanente Plan Physician
 Pre- and post-natal maternity care; no co-payment per pre-natal visit and initial post-partum visit.
Mental Health and Substance Abuse
The following mental health services are covered 100% after any applicable co-payment:
 In-patient facility treatment: $500 co-payment per admission applies, with no limitation on the
number of days.
 Out-patient care: A $25 office visit co-payment applies to individual treatment, and a $12 office
visit co-payment applies for group treatment with no limitation to the number of visits. The
following substance abuse services are covered 100% after any applicable co-payment:
 In-patient detoxification facility treatment: $500 co-payment per admission applies, with no
limitation on the number of days.
 Out-patient detoxification care: $5 group per visit co-payment; $25 per individual visit, copayment
applies, with no limitation on the number of days.
 In-patient rehabilitation services: $500 co-payment per admission applies, with no limitation on
the number of days, Transitional residential recovery service in non-medical setting can be
considered in-patient rehabilitation.
 Out-patient rehabilitation services: $25 per individual visit co-payment.
Vision Care
The following vision care expenses are covered:
 Annual routine exam: Plan pays 100% after $25 office visit co-payment.
 Regular lenses and frames or contact lenses: Not covered.
Physical Therapy and Chiropractic Care
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For physical therapy, plan pays 100% after $25 co-payment per visit. This is limited to medically
necessary therapy preauthorized by a plan physician.
Chiropractic care is not covered.
Reconstructive Surgery Following a Mastectomy
For covered women, the plan covers breast reconstruction benefits in connection with a mastectomy.
If reconstruction is elected, coverage is available in a manner determined in consultation with your doctor
for the following:
 Reconstruction of the breast on which the mastectomy was performed;
 Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
 Prosthesis and treatment for physical complications for all stages of the mastectomy, including
lymphedemas.
Coverage is subject to the terms of your plan option in effect at the time of reconstruction, including
co-payments, deductibles, and coinsurance as applicable for other covered expenses.
State Mandated Benefits
Certain coverage limits and benefits may apply based on your state. Call your plan’s member services if
you have questions.
What’s Not Covered
The following services and supplies are not covered:
Note: This list is not all-inclusive. Call member services if you have questions.
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Physical exams and other services required for obtaining or maintaining employment or
participation in employee programs, required for insurance or licensing, or on court order or
required for parole or probation;
Chiropractic services;
All services (other than artificial insemination) related to conception by artificial means;
Cosmetic services that are intended primarily to improve your appearance, except for services
covered as a result of a mastectomy;
Hair loss or growth treatment services for the promotion, prevention, or other treatment of hair loss
or hair growth;
Intermediate care;
Routine foot care services;
Sexual reassignment surgery;
Speech therapy unless medically necessary;
Surrogacy; and
Travel and lodging expenses.
Filing Medical Plan Claims
Kaiser HMO
You don’t need to file a claim form for in-network services. Your Health Maintenance Organization
(HMO) provider will submit the expense directly to the claims administrator. If you use an out-of-network
provider, the services may not be covered. If you have questions, call member services directly. The
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telephone number is on your plan ID card. For more information about filing claims and your right to
appeal a denied claim, see “Health and Insurance Plans Claims Review Procedures.”
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B.3 PRESCRIPTIONS
Prescription Drug Coverage under the Aetna Medical Plan Options
Eligibility for Coverage
You and your covered dependents are automatically covered by the Express Scripts Prescription Drug
Program if you enroll in any of the SPE Aetna Medical Plans. If you enroll in the Kaiser Health
Maintenance Organization (HMO), Kaiser will provide prescription drug coverage directly to you and
your covered dependents.
After you enroll, you’ll receive your prescription drug program ID card to use when filling retail
pharmacy prescriptions as well as Express Scripts by Mail home delivery service information. Also, you
can use the program’s Web site to register and access more information or call member services with
questions about your prescription drug coverage.
Creditable Coverage (Medicare Part D)
If you or a covered dependent is eligible for Medicare or will soon become eligible, you’re also eligible for
Medicare prescription drug coverage (Part D). You don’t need to enroll in Medicare Part D if your
Prescription Drug Program coverage is creditable, which means that your coverage is as good as Medicare
Part D standard coverage. SPE provides creditable prescription drug coverage with all its health plans. For
more information about your Prescription Drug Program coverage, call an SPE Benefits Connection
representative at 1-866-941-4773.
How the Prescription Drug Program Works
The Prescription Drug Program covers medically necessary drugs and medicines prescribed by your or
your covered dependent’s doctor on an out-patient basis. Some drugs and medicines aren’t covered by the
program. The Prescription Drug Program has two parts:
 For your immediate prescription needs—the retail pharmacy service is available. Simply present your
prescription drug ID card with your prescription(s) to the pharmacist at any participating pharmacy.
You can receive up to a thirty day supply of medications (as prescribed by your doctor). The
pharmacist will tell you the appropriate amount to pay. You do not have to submit a claim. Note that
over-the-counter medications, with a prescription, are not covered but may be reimbursed under your
Health Care Spending Account.
 If you have a health condition that requires the use of medication on an ongoing basis, you will need to
order your maintenance medications through Express Scripts mail-order services. You will need to
contact your doctor to prescribe up to a ninety day supply for home delivery, plus refills for up to one
year. If you do not use the mail order program after three fills at retail, you will pay 100% of the cost of
the medication.
Maximum of Three (3) Refills at a Retail Pharmacy
You may fill your initial prescription and get up to two refills at a retail pharmacy for any maintenance
drug and receive full benefits. However, after the second refill at retail pharmacy for the maintenance
medication, Express Scripts will notify you that you must begin to order your prescription drugs through
the mail order program. Instructions will accompany the notification. After that, you must order a ninety
day supply through Express Scripts by Mail in order to receive benefits. If you forget and refill your
prescription again at a retail pharmacy, you will not receive benefits. This means that while you can still
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fill your prescription at retail, you will be responsible for the full cost of any maintenance medication after
your third purchase at retail unless you use the mail order program.
Generic and Formulary Drugs
If you purchase your prescription at a retail pharmacy and choose a formulary or non-formulary brand
drug when a generic equivalent is available, in addition to your coinsurance, you’ll also pay the program’s
cost difference between the brand and the generic.
If your prescription is not on the formulary list, your doctor may be able to prescribe a generic or
formulary substitute that’s equally effective but less costly.
A formulary is an approved list for commonly prescribed brand drugs that are chosen based on their
combination of medical effectiveness and cost. To obtain a copy of the formulary at no cost, go to Express
Scripts web site or call Express Scripts member services. At a participating retail pharmacy, there are no
claim forms to complete. You just pay the appropriate amount when you pick up your prescription. At a
non-participating pharmacy, you must pay the full cost up front and then submit a claim form.
Reimbursement is based on the participating pharmacy’s discounted cost minus the co-payment. To
obtain a form, contact Express Scripts. If your claim is denied, you have the right to appeal. Ongoing
medications are less costly when ordered through the mail and in larger amounts, such as a ninety day
supply.
For a prescription filled by Express Scripts by Mail, a generic, if available, is automatically substituted
unless your doctor states “no substitutions” on the prescription.
If a prescription costs less than the co-payment, you should pay the cost out-of-pocket rather than filling
the prescription through the plan.
You can use your Health Care Spending Account to receive reimbursement for your share of prescription
drug costs. Specialty drugs are required to be obtained through Express Scripts Accredo Mail Order
Pharmacy. Please call 1-800-926-1662 for more information.
Coverage Management
Some medications covered by the Plan are limited to certain uses or available only in certain quantities.
For example, a medication may not be covered when it is used for cosmetic purposes.
Also, the quantity covered may be limited to certain amounts over certain time periods. Your doctor may
be required to provide more information to determine if your prescription meets Plan coverage criteria.
Prior authorization is a process by which certain drugs (both at retail and home delivery) are reviewed and
approved by Express Scripts before they are covered under the Prescription Drug Program.
Certain drugs require prior authorization and clinical management by Express Scripts pharmacists
because the designated drug(s):
 May be used for an inappropriate diagnosis or condition
 Are potent agents that require closer scrutiny of therapeutic approach, dosing duration and/or
potential side effects of therapy
 Are used for multiple diagnoses or conditions, some of which are not covered by the plan
 May be prescribed in an excessive amount
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Your physician must call Express Scripts Managed Care Service at 1-800-753-2851 to begin the coverage
review process to obtain approval before prescribing certain drugs including but not limited to anti-obesity
agents, central nervous system stimulants, growth hormones, Provigil, and Retin-A.
Note: SPE reserves the right to limit coverage for certain prescription drugs for any reason, including, but
not limited to, cost management, safety, usage management, or because a drug is prescribed strictly for
cosmetic purposes.
Preventive Medications
As previously indicated, PPACA requires certain plans to provide enumerated preventive services at no
cost to you based on issued guidelines and recommendations. Included in those guidelines and
recommendations are certain medications such as aspirin, fluoride, folic acid. Immunizations/vaccines,
iron supplements, smoking cessation products, and women’s contraceptives that must also be covered at
no-cost when prescribed by your health care provider.
There are limitations however. For example, the plan retains the flexibility to control costs and may
continue to impose cost sharing for branded drugs if a generic version is available and just as effective and
safe.
Drugs That Are Limited or Not Covered
Certain drugs and medicines aren’t covered by the plan (subject to those preventive medications covered
in accordance with PPACA). Also, your payments for excluded medications can’t be used to satisfy your
medical plan’s deductible or out-of-pocket limit.
You can use the Express Scripts website to find participating retail pharmacies near you, get the most
recent formulary list, compare drug alternatives and prices, and order home delivery service refills using a
credit card for payment; or you can also call member services directly.
Here are examples of drugs and medicines that the plan does not cover. This list isn’t exhaustive.
 Non-federal legend drugs (i.e., over-the-counter products).
 Mifeprex.
 Therapeutic devices or appliances.
 Drugs whose sole purpose is to promote or stimulate hair growth (e.g., Rogaine, Propecia) or for
cosmetic purposes only (e.g., Renova, Vaniqa, Tri-Luma, Botox Cosmetic, Avage, Solage,
Epiquin).
 Experimental drugs labeled “Caution-limited by federal law to investigational use,” or
experimental drugs, even though a charge is made to the individual.
 Medication for which the cost is recoverable under any Workers’ Compensation or occupational
disease law or any state or governmental agency, or medication furnished by any other drug or
medical service for which no charge is made to the member.
 Medication which is to be taken by or administered to an individual, in whole or in part, while he
or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled
nursing facility, convalescent hospital, nursing home, or similar institution which operates on its
premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
 Any prescription refilled in excess of the refill number specified by the physician, or any refill
dispensed after one year from the physician’s original order.
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Charges for the administration or injection of any drug.
Also, for drugs to treat impotency/erectile dysfunction for men age 18 and over, coverage is limited to:
 Thirty days or eight units, whichever is less for a retail pharmacy prescription.
 Ninety days or thirty units, whichever is less for a mail-order prescription.
If you have any questions about whether a medication is covered, contact Express Scripts Health Solutions
directly at www.express-scripts.com. The telephone number is listed on your Prescription Drug Program
ID card.
Aetna Consumer Choice Plan & Prescriptions
For the most part, until you reach the deductible under the Aetna Consumer Choice Plan, you will pay
100% of the negotiated rate for a prescription.
However, many preventive medications that can help you avoid or curtail certain illnesses and conditions
are covered at 100%. This list includes medications used for prevention or for treatment.
Conditions that can be covered include:
• Asthma
• Diabetes
• Heart disease
• Cholesterol
• Side effects of cancer
• High blood pressure
For a complete list of covered prescriptions, go to www.KENKOatSPE.com or
www.expressscripts.com/sonypics.
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B.4 VISION
Coverage Categories
If you enroll in any SPE medical plan, you will automatically be enrolled in the Vision Plan, you’ll be
assigned to a coverage category based on the number of dependents you cover.
The coverage category affects the price you pay for the coverage:
 Employee Only;
 Employee Plus Spouse/ Domestic Partner;
 Employee Plus Child(ren); and
 Employee Plus Family.
Vision Plan Options
You are automatically covered if you elect coverage for any of the SPE medical plans.
Cost of Coverage
The cost of coverage is included in your medical cost of coverage with before-tax deductions from your
paycheck. Costs are subject to review and updating annually by SPE. You’ll be notified of any changes to
cost during annual enrollment.
How the Plan Works
Vision Plan coverage is provided through Vision Service Plan (VSP), which has a network of participating
optometrists and ophthalmologists that provide vision care services at negotiated rates. You can get a list
of VSP doctors in your area by using their Web site at www.vsp.com (or calling VSP’s member services
at 1-800-877-7195). If you choose coverage, your benefits depend on whether you use in-network or
out-of-network doctors.
You can seek vision care from any licensed optometrist, ophthalmologist, or optician. However:
If you use a VSP doctor, you receive the highest level of benefits.
If you use out-of-network:
 You receive limited benefits according to a fixed schedule.
 You need to file a claim with the Vision Plan administrator to be reimbursed.
While covered by the plan, you have certain rights and protections, including privacy of your health
information.
Changing Your Option
After enrolling in the Vision Plan, you can only change your option:
 During annual enrollment;
 If you have a qualified status change; or
 If the contract between SPE and VSP ends.
Vision Plan Benefits
The amount the plan pays for expenses relating to eye exams, glasses, and contact lenses depends on
whether or not you use a VSP doctor. If you or a covered dependent has a vision care expense that is also
covered by another plan, coordination of benefits may apply.
If You Use VSP In-Network Doctors
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If you use a VSP in-network doctor, here’s what the plan covers each calendar year for each covered
person after the $25 annual co-payment:
 Annual eye exam
 Glasses or Contact Lenses
The plan pays:
 For frames, up to $120 retail allowance once per calendar year; 20% discount off amount over your
allowance.
 For lenses, the full amount except the cost of lens enhancements (such as polycarbonate lenses or
special coatings); average 35-40% discount off the ususal and customary cost of most lens options
 Elective contact lenses (instead of eyeglasses) - The plan pays up to $120 for contacts and fitting.
There is a 15% discount on the contact lens exam (fitting/evaluation), which is performed in addition to
the routine eye exam; limited to once per calendar year.
 Medically necessary contact lenses - The plan pays 100% after copay.
 Laser vision correction surgery - Available to plan participants at a reduced rate when performed by a
participating provider. Go to www.vsp.com for details. After surgery, use your Frame benefit (if
eligible) for non-prescription sunglasses from any VSP doctor.
 Low vision benefit (special aid for people with severe visual problems and who are referred to as
“partially sighted” must be approved by VSP).
You pay 25% of the cost of any approved low vision program subject to a $1,000 benefit
maximum every 2 years
*Contact lens benefit is instead of eyeglasses (lenses and frame).
If You Use Out-of-Network Services*
If you use an out-of-network provider, the $25 co-payment applies. Here’s what the plan pays for services
each calendar year per covered person:
 Annual eye exams-- The plan pays up to $50
 Eyeglasses or Contact Lenses (see below)
The plan pays up to these scheduled amounts:
 Frames—$70
 Lenses—(per pair):
o Single vision $50
o Lined bifocal $75
o Lined trifocal $100
o Lenticular $125
o Tints/Photochromics $5
 Elective contact lenses (instead of eyeglasses) $105
 Medically necessary contact lenses The plan pays up to $210
*Note: You need to file a claim to be reimbursed for your out-of-network expenses based on the plan’s
reimbursement schedule.
Additional Benefits
Lens Enhancements
The following lens enhancements can be ordered whether you use a VSP network provider or a
non-participating provider. You pay the additional charge for these options. Using a VSP provider, you’ll
generally save 35-40%.
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Blended lenses;
Oversize lenses;
Progressive multifocal lenses;
Coated or laminated lenses;
UV-protected lenses;
Cosmetic lenses; and
Any other optional cosmetic process
Laser Vision Correction Surgery Discount
VSP has arranged for plan participants to receive laser vision correction surgery at a discounted fee from
contracted facilities. Go to VSP’s Web site at www.vsp.com or call VSP for additional information about
the procedure. Consult with your eye doctor to determine if laser vision correction makes sense for you.
You receive an average 15% off the regular price or 5% off the promotional price. Also, if you contribute
to your Health Care Spending Account, you can claim laser vision correction surgery expenses through
your account and receive a tax-free reimbursement of these expenses.
Low Vision Benefit
The low vision benefit provides special aid for people who have severe visual problems. If you or a
covered dependent qualifies, you’ll be eligible for low vision services and associated materials subject to
certain limitations.
The treatment plan and charges must be approved before services are rendered. VSP doctors have the
forms to submit for approval. You’re required to pay 25% of the cost of any approved low vision program.
The plan has a $1,000 benefit maximum (excluding co-payments) every two years. The maximum
includes the cost for supplementary testing.
What’s Not Covered
Certain vision services and supplies are excluded expenses under the plan.
The vision plan is designed to cover your basic vision needs. If you want to purchase certain optional
services and materials, such as types of lenses that are considered cosmetic, you’ll be responsible for the
cost.
Here are examples of expenses that the plan doesn’t cover. This list isn’t exhaustive.
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Preventive or diagnostic exams as well as medical or surgical treatment of the eye. (Exception: You
can receive a discount on fees for laser vision correction surgery at participating providers. Also,
certain medical treatment may be covered by your medical plan.)
An eye exam or corrective eye wear required as a condition of employment.
More than one pair of prescription lenses (either eyeglasses or contacts) and frames and more than one
vision exam annually.
The extra charge for lenses that are blended, coated, oversized, progressive multifocal, laminated,
UV-protected, or polycarbonate
Two pairs of glasses instead of bifocals.
Replacement of lost or broken lenses and frames, unless the replacement would otherwise be paid for
as part of your annual services.
Orthoptics or vision training and any associated supplemental testing.
Plano or lenses with a prescription of less than .50 diopter power.
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If you have any questions about whether an expense is covered, contact the Claims Administrator or
call the SPE Benefits Connection at 1-866-941-4773.
Filing Vision Plan Claims
For Expenses from a VSP Doctor
When you make your appointment with a VSP doctor, identify yourself as a Vision Service Plan (VSP)
member. You pay the $25 annual co-payment as well as any additional cost for cosmetic lens
enhancements, any portion of the frame cost in excess of your allowance or elective contact lens costs in
excess of your allowance. Your VSP provider will submit claims for you.
For the low vision benefit, VSP doctors will submit claim forms for approval.
For Out-of-Network Expenses
When you have out-of-network vision care expenses, you need to pay the entire bill. You should request
an itemized bill that shows the amount of the eye exam, lens type, and frame. Also include employee’s
name, Social Security number and mailing address, patient’s name, relationship to employee, and date of
birth. Then file a claim for reimbursement. Log on to VSP’s Web site at www.vsp.com for instructions on
filing a claim. Or call Customer Service at (800) 877-7195
How to Appeal Denied Claims
Once you turn in your vision claim, the Claims Administrator will review the claim and make a decision.
Claims may be denied in some situations. If you need assistance resolving a claim, you can use Participant
Advocacy Services, which are available through SPE Benefits Connection.
Call 1-866-941-4773 and speak with an SPE Benefits Connection representative. You have the right to
appeal denied claims by following the claim review process.
Right of Recovery
If any claim or benefit is overpaid, the plan reserves the right to recover the overpayment or to reduce any
future payments. The person receiving the benefit must produce any instruments or papers necessary to
ensure this right of recovery.
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B.5 DENTAL PPO
PLAN FEATURES
Calendar Year
Deductible
NETWORK
Individual None
Family None
OUT-OF-NETWORK
Individual $50
Family 150
The Calendar Year deductible applies to all covered expenses except Type A Expenses.
Please refer to the listing of covered expenses and the percentage payable appearing below. The percentage the
plan will pay varies by the type of expense.
PLAN PAYMENT
PERCENTAGE
Type A Expenses
NETWORK PAYMENT
PERCENTAGE
100%
OUT-OF-NETWORK
PAYMENT PERCENTAGE
100%
Type B Expenses
90%
80%
Type C Expenses
60%
50%
50%
50%
Calendar Year Maximum Benefit
Calendar Year Maximum:
$2,000
The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called
the Calendar Year Maximum Benefit.
The Calendar Year maximum benefit applies to network and out-of-network covered dental expenses combined.
Orthodontic Lifetime Maximum Benefit
Orthodontic Lifetime Maximum:
$2,000
Dental Emergency Maximum Benefit
Dental Emergency Maximum:
$75
The most the plan will pay for covered expenses incurred by a covered person for any one Dental Emergency is
called the Dental Emergency Maximum.
Expense Provisions
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You and each of your covered dependents have separate Calendar Year deductibles. Each of you must meet your
deductible separately and they cannot be combined. This Plan has individual and family Calendar Year
deductibles.
Individual
from an out-of-network provider for which no benefits will be paid. This individual Calendar Year deductible
applies separately to you and each of your covered dependents. After covered expenses reach this individual
Calendar Year deductible; this Plan will begin to pay benefits for covered expenses that you incur from an
out-of-network provider for the rest of the Calendar Year.
The combined covered expenses that you and each of your covered dependents incur towards the
individual Calendar Year deductibles must reach this family deductible limit in a Calendar Year.
Payment Provisions
Payment Percentage
Maximum Benefit Provisions
Calendar Year Maximum Benefit
The most the plan will pay for covered expenses incurred by any one covered person in a Calendar Year is called the
Calendar Year maximum benefit.
The Calendar Year maximum benefit applies to network care and out-of-network care expenses combined.
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What the Plan Covers and How Benefits Are Paid
Aetna Dental PPO
Preface
The dental benefits plan described in this Benefit Description is a benefit plan of the Employer. These
benefits are not insured with Aetna but will be paid from the Employer's funds. Aetna will provide certain
administrative services under the Aetna dental benefits plan.
Aetna agrees with the Employer to provide administrative services in accordance with the conditions,
rights, and privileges as set forth in this Benefit Description. The Employer selects the products and
benefit levels under the Aetna dental benefits plan.
The Benefit Description describes your rights and obligations, what the Aetna dental benefits plan covers,
and how benefits are paid for that coverage. It is your responsibility to understand the terms and conditions
in this Benefit Description. Your Benefit Description includes the Schedule of Benefits and any
amendments.
This Benefit Description replaces and supercedes all Aetna Benefit Descriptions describing coverage for
the dental benefits plan described in this Benefit Description that you may previously have received.
Employer:
Contract Number:
Effective Date:
810072
January 1, 2015
ID Cards
If you are an enrollee with Aetna Dental coverage, you don't need an ID card. When visiting a dentist,
simply provide your name, date of birth and Member ID# (or social security number). The dental office
can use that information to verify your eligibility and benefits. If you still would like an ID card for you
and your dependents, you can print a customized ID card by going to the secure member website at
www.aetna.com. You can also access your benefits information when you’re on the go. To learn more,
visit us at www.aetna.com/mobile or call us at 1-877-238-6200.
Benefits are payable for covered health care expenses that are incurred by you or your covered dependents
while coverage is in effect. An expense is “incurred” on the day you receive a health care service or
supply.
Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational
illnesses are covered.
Refer to the What the Plan Covers section of the Benefit Description for more information about your
coverage.
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Aetna is not a provider of health care services and therefore is not responsible for and does not guarantee
any results or outcomes of the covered health care services and supplies you receive. Except for Aetna RX
Home Delivery LLC, providers of health care services, including hospitals, institutions, facilities or
agencies, are independent contractors and are neither agents nor employees of Aetna or its affiliates.
Throughout this section you will find information on who can be covered under the plan, how to enroll and
what to do when there is a change in your life that affects coverage. In this section, “you” means the
employee.
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Be included as a covered expense in this Benefit Description;
Not be an excluded expense under this Benefit Description. Refer to the Exclusions sections of this
Benefit Description for a list of services and supplies that are excluded;
Not exceed the maximums and limitations outlined in this Benefit Description. Refer to the What
the Plan Covers section and the Schedule of Benefits for information about certain expense limits;
and
Be obtained in accordance with all the terms, policies and procedures outlined in this Benefit
Description.
2. The service or supply must be provided while coverage is in effect. See the Who Can Be Covered, How
and When to Enroll, When Your Coverage Begins, When Coverage Ends and Continuation of
Coverage sections for details on when coverage begins and ends.
3. The service or supply must be medically necessary. To meet this requirement, the dental service or
supply must be provided by a physician, or other health care provider or dental provider, exercising
prudent clinical judgment, to a patient for the purpose of preventing, evaluating, diagnosing or treating
an illness, injury, disease or its symptoms. The provision of the service or supply must be:
(a) In accordance with generally accepted standards of dental practice;
(b) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered
effective for the patient’s illness, injury or disease; and
(c) Not primarily for the convenience of the patient, physician or dental provider or other health care
provider;
equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness,
injury, or disease.
For these purposes “generally accepted standards of dental practice” means standards that are based on
credible scientific evidence published in peer-reviewed dental literature generally recognized by the
relevant dental community, or otherwise consistent with physician or dental specialty society
recommendations and the views of physicians or dentists practicing in relevant clinical areas and any
other relevant factors.
Important Note
 Not every service or supply that fits the definition for medical necessity is covered by the plan.
Exclusions and limitations apply to certain dental services, supplies and expenses. For example some
benefits are limited to a certain number of days, visits or a dollar maximum. Refer to the What the Plan
Covers section and the Schedule of Benefits for the plan limits and maximums.
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How the Aetna Dental Plan Works
Understanding Your Aetna Dental Plan
It is important that you have the information and useful resources to help you get the most out of your
Aetna dental plan. This Benefit Description explains:
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What services and supplies are covered and what limits may apply;
What services and supplies are not covered by the plan;
Other important information such as eligibility, complaints and appeals, termination, continuation of
coverage and general administration of the plan.
Important Notes:
Unless otherwise indicated, "you" refers to you and your covered dependents.
This Benefit Description applies to coverage only and does not restrict your ability to receive covered
expenses that are not or might not be covered expenses under this dental plan.
Getting Started: Common Terms
Many terms throughout this Benefit Description are defined in the Glossary Section at the back of this
document. Defined terms appear in bolded print. Understanding these terms will also help you understand
how your plan works and provide you with useful information regarding your coverage.
About the PPO Dental Plan
The plan is a Preferred Provider Organization (PPO) that covers a wide range of dental services and
supplies. You can visit the dental provider of your choice when you need dental care.
You can choose a dental provider who is in the dental network. You may pay less out of your own pocket
when you choose a network provider.
You have the freedom to choose a dental provider who is not in the dental network. You may pay more if
you choose an out-of-network provider.
The Schedule of Benefits shows you how the plan's level of coverage is different for network services and
supplies and out-of network services and supplies.
The Choice is Yours
You have a choice each time you need dental care:
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Using Network Providers
 You will receive the plan's higher level of coverage when your care is provided by a network
provider.
 The plan begins to pay benefits after you satisfy a deductible.
 You share the cost of covered services and supplies by paying a portion of certain expenses (your
payment percentage). Network providers have agreed to provide covered services and supplies at a
negotiated charge. Your payment percentage is based on the negotiated charge. In no event will
you have to pay any amounts above the negotiated charge for a covered service or supply. You have
no further out-of pocket expenses when the plan covers in network services at 100%.
 You will not have to submit dental claims for treatment received from network providers. Your
network provider will take care of claim submission. You will be responsible for deductibles,
payment percentage and copayments, if any.
 You will receive notification of what the plan has paid toward your covered expenses. It will indicate
any amounts you owe towards your deductible, copayment, payment percentage or other
non-covered expenses you have incurred. You may elect to receive this notification by e-mail, or
through the mail. Call or e-mail Member Services if you have questions regarding your statement.
Aetna cannot guarantee the availability or continued participation of a particular provider. Either Aetna
or any network provider may terminate the provider contract or limit the number of patients accepted in
a practice.
Using Out-of-Network Providers
You can obtain dental care from dental providers who are not in the network. The plan covers
out-of-network services and supplies, but your expenses will generally be higher.
You must satisfy a deductible before the plan begins to pay benefits.
You share the cost of covered services and supplies by paying a portion of certain expenses (your
payment percentage).
If your out-of-network provider charges more than the recognized charge, you will be responsible for
any expenses incurred above the recognized charge. The recognized charge is the maximum amount
Aetna will pay for a covered expense from an out-of network provider.
You must file a claim to receive reimbursement from the plan.
Important Reminder
Refer to the Schedule of Benefits for details about any deductibles, copays, payment percentage and
maximums that apply. There is a separate maximum that applies to orthodontic treatment.
Getting an Advance Claim Review
The purpose of the advance claim review is to determine, in advance, the benefits the plan will pay for
proposed services. Knowing ahead of time which services are covered by the plan, and the benefit amount
payable, helps you and your dentist make informed decisions about the care you are considering.
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Important Note
The pre-treatment review process is not a guarantee of benefit payment, but rather an estimate of the
amount or scope of benefits to be paid.
When to Get an Advance Claim Review
An advance claim review is recommended whenever a course of dental treatment is likely to cost more
than $300. Ask your dentist to write down a full description of the treatment you need, using either an
Aetna claim form or an ADA approved claim form. Then, before actually treating you, your dentist
should send the form to Aetna. Aetna may request supporting x-rays and other diagnostic records. Once
all of the information has been gathered, Aetna will review the proposed treatment plan and provide you
and your dentist with a statement outlining the benefits payable by the plan. You and your dentist can
then decide how to proceed.
The advance claim review is voluntary. It is a service that provides you with information that you and your
dentist can consider when deciding on a course of treatment. It is not necessary for emergency treatment
or routine care such as cleaning teeth or check-ups.
In determining the amount of benefits payable, Aetna will take into account alternate procedures, services,
or courses of treatment for the dental condition in question in order to accomplish the anticipated result.
(See Benefits When Alternate Procedures Are Available for more information on alternate dental
procedures.)
What is a Course of Dental Treatment?
A course of dental treatment is a planned program of one or more services or supplies. The services or
supplies are provided by one or more dentists to treat a dental condition that was diagnosed by the
attending dentist as a result of an oral examination. A course of treatment starts on the date your dentist
first renders a service to correct or treat the diagnosed dental condition.
In Case of a Dental Emergency
The plan pays a benefit at the network level of coverage even if the services and supplies were not
provided by a network provider up to the dental emergency maximum. The care provided must be a
covered service or supply. You must submit a claim to Aetna describing the care given. Additional dental
care to treat your dental emergency will be covered at the appropriate coinsurance level.
What The Plan Covers
PPO Dental Plan
Schedule of Benefits for the PPO Dental Plan
PPO Dental is merely a name of the benefits in this section. The plan does not pay a benefit for all dental
care expenses you incur.
Important Reminder
Your dental services and supplies must meet the following rules to be covered by the plan:
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The services and supplies must be medically necessary.
The services and supplies must be covered by the plan.
You must be covered by the plan when you incur the expense.
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Covered expenses include charges made by a dentist for the services and supplies that are listed in the
dental care schedule.
The next sentence applies if:
 A charge is made for an unlisted service given for the dental care of a specific condition; and
 The list includes one of more services that, under standard practices, are separately suitable for the
dental care of that condition.
In that case, the charge will be considered to have been made for a service in the list that Aetna determines
would have produced a professionally acceptable result.
Dental Care Schedule
The dental care schedule is a list of dental expenses that are covered by the plan. There are several
categories of covered expenses:
 Preventive
 Diagnostic
 Restorative
 Oral surgery
 Endodontics
 Periodontics
 Orthodontics
These covered services and supplies are grouped as Type A, Type B or Type C.
Coverage is also provided for a dental emergency. Services provided for a dental emergency will be
covered at the network level of benefits even if services and supplies are not provided by a network
provider. There is a maximum benefit payable. For additional information, please refer to In Case of a
Dental Emergency section.
Important Reminder
The deductible, payment percentage and maximums that apply to each type of dental care are shown in
You may receive services and supplies from network and out-of-network providers. Services and
supplies given by a network provider are covered at the network level of benefits shown in the
Schedule of Benefits. Services and supplies given by an out-of-network provider are covered at the
out-of-network level of benefits shown in the Schedule of Benefits.
Refer to About the PPO Dental Coverage for more information about covered services and supplies.
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Type A Expenses: Diagnostic and Preventive Care
Visits and X-Rays
Office visit during regular office hours, for oral examination
Routine comprehensive or recall examination or Problem-focused exams (limited to 2 visits
every year)
Prophylaxis (cleaning) (limited to 3 treatments per year)
Adult
Child
Topical application of fluoride, (limited to one course of treatment per year and to children under age
18)
Sealants, per tooth (limited to one application every 3 years for permanent molars only)
Bitewing X-rays (limited to 2 sets per year)
Complete X-ray series, including bitewings if necessary, or panoramic film (limited to 1 set every 3
years)
Vertical bitewing X-rays (limited to 1 set every 3 years)
Type B Expenses: Basic Restorative Care
Visits and X-Rays
Professional visit after hours (payment will be made on the basis of services rendered or visit,
whichever is greater)
Emergency palliative treatment, per visit
X-Ray and Pathology
Periapical x-rays (single films up to 13)
Intra-oral, occlusal view, maxillary or mandibular
Upper or lower jaw, extra-oral
Biopsy and histopathologic examination of oral tissue
Oral Surgery
Extractions
Erupted tooth or exposed root
Coronal remnants
Surgical removal of erupted tooth/root tip
Impacted Teeth
Removal of tooth (soft tissue)
Removal of tooth (partially bony)
Removal of tooth (completely bony)
Odontogenic Cysts and Neoplasms
Incision and drainage of abscess
Removal of odontogenic cyst or tumor
Other Surgical Procedures
Alveoplasty, in conjunction with extractions - per quadrant
Alveoplasty, in conjunction with extractions, 1 to 3 teeth or tooth spaces - per quadrant
Alveoplasty, not in conjunction with extraction - per quadrant
Alveoplasty, not in conjunction with extractions, 1 to 3 teeth or tooth spaces - per quadrant
Sialolithotomy: removal of salivary calculus
Closure of salivary fistula
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Excision of hyperplastic tissue
Removal of exostosis
Transplantation of tooth or tooth bud
Closure of oral fistula of maxillary sinus
Sequestrectomy
Crown exposure to aid eruption
Removal of foreign body from soft tissue
Frenectomy
Suture of soft tissue injury
Periodontics
Occlusal adjustment (other than with an appliance or by restoration)
Root planing and scaling, per quadrant (limited to 4 separate quadrants every year)
Root planing and scaling – 1 to 3 teeth per quadrant (limited to once per site every year)
Gingivectomy, per quadrant
Gingivectomy, 1 to 3 teeth per quadrant
Gingival flap procedure - per quadrant
Gingival flap procedure – 1 to 3 teeth per quadrant
Osseous surgery (including flap and closure), 1 to 3 teeth per quadrant
Osseous surgery (including flap and closure), per quadrant
Soft tissue graft procedures
Endodontics
Pulp capping
Pulpotomy
Apexification/recalcification
Apicoectomy
Root canal therapy including necessary X-rays
Anterior
Bicuspid
Molar
Restorative Dentistry Excludes inlays, crowns (other than prefabricated stainless steel or resin) and
bridges. (Multiple restorations in 1 surface will be considered as a single restoration.)
Amalgam restorations
Resin-based composite restorations (other than for molars)
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Pins
Pin retention—per tooth, in addition to amalgam or resin restoration
Crowns (when tooth cannot be restored with a filling material)
Prefabricated stainless steel
Prefabricated resin crown (excluding temporary crowns)
Recementation
Inlay
Crown
Bridge
Space Maintainers Only when needed to preserve space resulting from premature loss of primary
teeth. (Includes all adjustments within 6 months after installation.)
Fixed (unilateral or bilateral)
Removable (unilateral or bilateral)
Prosthodontics
Full and partial denture repairs
Broken dentures, no teeth involved
Repair cast framework
Replacing missing or broken teeth, each tooth
Adding teeth to existing partial denture
Each tooth
Each clasp
Repairs: crowns and bridges
Occlusal guard (for bruxism only)
General Anesthesia and Intravenous Sedation (only when medically necessary and only when
provided in conjunction with a covered surgical procedure)
Type C Expenses: Major Restorative Care
Restorative. Inlays, onlays, labial veneers and crowns are covered only as treatment for decay or acute
traumatic injury and only when teeth cannot be restored with a filling material or when the tooth is an
abutment to a fixed bridge (limited to 1 per tooth every 5 years- see Replacement Rule).
Inlays/Onlays
Labial Veneers
Laminate-chairside
Resin laminate – laboratory
Porcelain laminate – laboratory
Crowns
Resin
Resin with noble metal
Resin with base metal
Porcelain/ceramic substrate
Porcelain with noble metal
Porcelain with base metal
Base metal (full cast)
Noble metal (full cast)
3/4 cast metallic or porcelain/ceramic
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Post and core
Prosthodontics- First installation of dentures and bridges is covered only if needed to replace teeth
extracted while coverage was in force and which were not abutments to a denture or bridge less than 5
years old. (See Tooth Missing But Not Replaced Rule.) Replacement of existing bridges or dentures is
limited to 1 every 5 years. (See Replacement Rule.)
Bridge Abutments (See Inlays and Crowns)
Pontics
Base metal (full cast)
Noble metal (full cast)
Porcelain with noble metal
Porcelain with base metal
Resin with noble metal
Resin with base metal
Removable Bridge (unilateral)
One piece casting, chrome cobalt alloy clasp attachment (all types) per unit, including pontics
Dentures and Partials (Fees for dentures and partial dentures include relines, rebases and adjustments
within 6 months after installation. Fees for relines and rebases include adjustments within 6 months
after installation. Specialized techniques and characterizations are not eligible.)
Complete upper denture
Complete lower denture
Partial upper or lower, resin base (including any conventional clasps, rests and teeth)
Partial upper or lower, cast metal base with resin saddles (including any conventional clasps, rests
and teeth)
Stress breakers
Interim partial denture (stayplate), anterior only
Office reline
Laboratory reline
Special tissue conditioning, per denture
Rebase, per denture
Adjustment to denture more than 6 months after installation
Orthodontics
Interceptive orthodontic treatment
Limited orthodontic treatment
Comprehensive orthodontic treatment of adolescent dentition
Comprehensive orthodontic treatment of adult dentition
Post treatment stabilization
Removable appliance therapy to control harmful habits
Fixed appliance therapy to control harmful habits
Rules and Limits That Apply to the Dental Plan
Several rules apply to the dental plan. Following these rules will help you use the plan to your advantage
by avoiding expenses that are not covered by the plan.
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Orthodontic Treatment Rule
The plan does not cover the following orthodontic services and supplies:
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Replacement of broken appliances;
Re-treatment of orthodontic cases;
Changes in treatment necessitated by an accident;
Maxillofacial surgery;
Myofunctional therapy;
Treatment of cleft palate;
Treatment of micrognathia;
Treatment of macroglossia;
Lingually placed direct bonded appliances and arch wires (i.e. "invisible braces"); or
Removable acrylic aligners (i.e. "invisible aligners").
The plan will not cover the charges for an orthodontic procedure if an active appliance for that procedure
was installed before you were covered by the plan.
Replacement Rule
Crowns, inlays, onlays and veneers, complete dentures, removable partial dentures, fixed partial dentures
(bridges) and other prosthetic services are subject to the plan's replacement rule. That means certain
replacements of, or additions to, existing crowns, inlays, onlays, veneers, dentures or bridges are covered
only when you give proof to Aetna that:
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While you were covered by the plan, you had a tooth (or teeth) extracted after the existing denture or
bridge was installed. As a result, you need to replace or add teeth to your denture or bridge.
The present crown, inlay and onlay, veneer, complete denture, removable partial denture, fixed partial
denture (bridge), or other prosthetic service was installed at least 5 years before its replacement and
cannot be made serviceable.
You had a tooth (or teeth) extracted while you were covered by the plan. Your present denture is an
immediate temporary one that replaces that tooth (or teeth). A permanent denture is needed, and the
temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months
from the date that the temporary denture was installed.
Tooth Missing but Not Replaced Rule
The first installation of complete dentures, removable partial dentures, fixed partial dentures (bridges),
and other prosthetic services will be covered if:
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The dentures, bridges or other prosthetic services are needed to replace one or more natural teeth that
were removed while you were covered by the plan; and
The tooth that was removed was not an abutment to a removable or fixed partial denture installed
during the prior 5 years. The extraction of a third molar does not qualify. Any such appliance or fixed
bridge must include the replacement of an extracted tooth or teeth.
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Alternate Treatment Rule (GR-9N-20-015-01)
Sometimes there are several ways to treat a dental problem, all of which provide acceptable results. When
alternate services or supplies can be used, the plan's coverage will be limited to the cost of the least
expensive service or supply that is:
 Customarily used nationwide for treatment, and
 Deemed by the dental profession to be appropriate for treatment of the condition in question. The
service or supply must meet broadly accepted standards of dental practice, taking into account your
current oral condition.
You should review the differences in the cost of alternate treatment with your dental provider. Of course,
you and your dental provider can still choose the more costly treatment method. You are responsible for
any charges in excess of what the plan will cover.
Coverage for Dental Work Begun Before You Are Covered by the Plan
The plan does not cover dental work that began before you were covered by the plan. This means that the
following dental work is not covered:
 An appliance, or modification of an appliance, if an impression for it was made before you were
covered by the plan;
 A crown, bridge, or cast or processed restoration, if a tooth was prepared for it before you were
covered by the plan; or
 Root canal therapy, if the pulp chamber for it was opened before you were covered by the plan.
Coverage for Dental Work Completed After Termination of Coverage
Your dental coverage may end while you or your covered dependent is in the middle of treatment. The
plan does not cover dental services that are given after your coverage terminates. There is an exception.
The plan will cover the following services if they are ordered while you were covered by the plan, and
installed within 30 days after your coverage ends.
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Inlays;
Onlays;
Crowns;
Removable bridges;
Cast or processed restorations;
Dentures;
Fixed partial dentures (bridges); and
Root canals.
"Ordered" means:
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For a denture: the impressions from which the denture will be made were taken.
For a root canal: the pulp chamber was opened.
For any other item: the teeth which will serve as retainers or supports, or the teeth which are being
restored:
 Must have been fully prepared to receive the item; and
 Impressions have been taken from which the item will be prepared.
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What The PPO Dental Plan Does Not Cover
Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or
approved by your physician or dentist. The plan covers only those services and supplies that are
medically necessary and included in the What the Plan Covers section. Charges made for the following
are not covered except to the extent listed under the What the Plan Covers section or by amendment
attached to this Benefit Description. In addition, some services are specifically limited or excluded. This
section describes expenses that are not covered or subject to special limitations.
These dental exclusions are in addition to the exclusions that apply to health coverage.
Any instruction for diet, plaque control and oral hygiene.
Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic surgery,
personalization or characterization of dentures or other services and supplies which improve alter or
enhance appearance, augmentation and vestibuloplasty, and other substances to protect, clean, whiten
bleach or alter the appearance of teeth; whether or not for psychological or emotional reasons; except to
the extent coverage is specifically provided in the What the Plan Covers section. Facings on molar crowns
and pontics will always be considered cosmetic.
Crown, inlays and onlays, and veneers unless:
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It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or
The tooth is an abutment to a covered partial denture or fixed bridge.
Dental implants, braces, mouth guards, and other devices to protect, replace or reposition teeth and
removal of implants.
Dental services and supplies that are covered in whole or in part:
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Under any other part of this plan; or
Under any other plan of group benefits provided by the contractholder.
Dentures, crowns, inlays, onlays, bridges, or other appliances or services used for the purpose of splinting,
to alter vertical dimension, to restore occlusion, or correcting attrition, abrasion, or erosion.
Except as covered in the What the Plan Covers section, treatment of any jaw joint disorder and
treatments to alter bite or the alignment or operation of the jaw, including temporomandibular joint
disorder (TMJ) treatment, orthognathic surgery, and treatment of malocclusion or devices to alter bite or
alignment.
First installation of a denture or fixed bridge, and any inlay and crown that serves as an abutment to
replace congenitally missing teeth or to replace teeth all of which were lost while the person was not
covered.
General anesthesia and intravenous sedation, unless specifically covered and only when done in
connection with another necessary covered service or supply.
Orthodontic treatment except as covered in the What the Plan Covers section.
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Pontics, crowns, cast or processed restorations made with high noble metals (gold or titanium).
Prescribed drugs; pre-medication; or analgesia.
Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances
that have been damaged due to abuse, misuse or neglect and for an extra set of dentures.
Services and supplies done where there is no evidence of pathology, dysfunction, or disease other than
covered preventive services.
Services and supplies provided for your personal comfort or convenience, or the convenience of any other
person, including a provider.
Space maintainers except when needed to preserve space resulting from the premature loss of deciduous
teeth.
Surgical removal of impacted wisdom teeth only for orthodontic reasons.
Treatment by other than a dentist. However, the plan will cover some services provided by a licensed
dental hygienist under the supervision and guidance of a dentist. These are:
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Scaling of teeth;
Cleaning of teeth; and
Topical application of fluoride.
Additional Items Not Covered By A Health Plan
Not every health service or supply is covered by the plan, even if prescribed, recommended, or approved
by your physician or dentist. The plan covers only those services and supplies that are medically
necessary and included in the What the Plan Covers section. Charges made for the following are not
covered except to the extent listed under the What The Plan Covers section or by amendment attached to
Acupuncture, acupressure and acupuncture therapy, except as provided in the What the Plan Covers
section.
Charges submitted for services by an unlicensed hospital, physician or other provider or not within the
scope of the provider’s license.
Charges submitted for services that are not rendered, or not rendered to a person not eligible for coverage
under the plan.
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Examinations:
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Any dental examinations:
 required by a third party, including examinations and treatments required to obtain or maintain
employment, or which an employer is required to provide under a labor agreement;
 required by any law of a government, securing insurance or school admissions, or professional or
other licenses;
 required to travel, attend a school, camp, or sporting event or participate in a sport or other
recreational activity; and
 any special medical reports not directly related to treatment except when provided as part of a
covered service.
Experimental or investigational drugs, devices, treatments or procedures, except as described in the
What the Plan Covers section.
Medicare: Payment for that portion of the charge for which Medicare or another party is the primary
payer.
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Cancelled or missed appointment charges or charges to complete claim forms;
Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient
did not have coverage (to the extent exclusion is permitted by law) including:
 Care for conditions related to current or previous military service; or
 Care while in the custody of a governmental authority.
Non-medically necessary services, including but not limited to, those treatments, services, prescription
drugs and supplies which are not medically necessary, as determined by Aetna, for the diagnosis and
treatment of illness, injury, restoration of physiological functions, or covered preventive services. This
applies even if they are prescribed, recommended or approved by your physician or dentist.
Routine dental exams and other preventive services and supplies, except as specifically provided in the
What the Plan Covers section.
Services rendered before the effective date or after the termination of coverage, unless coverage is
continued under the Continuation of Coverage section of this Benefit Description.
Work related: Any illness or injury related to employment or self-employment including any injuries
that arise out of (or in the course of) any work for pay or profit, unless no other source of coverage or
reimbursement is available to you for the services or supplies. Sources of coverage or reimbursement may
include your employer, workers’ compensation, or an occupational illness or similar program under local,
state or federal law. A source of coverage or reimbursement will be considered available to you even if
you waived your right to payment from that source. If you are also covered under a workers’
compensation law or similar law, and submit proof that you are not covered for a particular illness or
injury under such law, that illness or injury will be considered “non-occupational” regardless of cause.
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Health Expense Coverage for your fully handicapped dependent child may be continued past the
maximum age for a dependent child. However, such coverage may not be continued if the child has been
issued an individual medical conversion policy.
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he or she is not able to earn his or her own living because of mental retardation or a physical handicap
which started prior to the date he or she reaches the maximum age for dependent children under your
plan; and
he or she depends chiefly on you for support and maintenance.
Proof that your child is fully handicapped must be submitted to Aetna no later than 31 days after the date
your child reaches the maximum age under your plan.
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Cessation of the handicap.
Failure to give proof that the handicap continues.
Failure to have any required exam.
Termination of Dependent Coverage as to your child for any reason other than reaching the maximum
age under your plan.
Aetna will have the right to require proof of the continuation of the handicap. Aetna also has the right to
examine your child as often as needed while the handicap continues at its own expense. An exam will not
be required more often than once each year after 2 years from the date your child reached the maximum
age under your plan.
Coordination of Benefit – What Happens When There is More Than One Health
Plan
Some persons have health coverage in addition to coverage under this Plan. Under these circumstances, it
is not intended that a plan provide duplicate benefits. For this reason, many plans, including this Plan,
have a "coordination of benefits" provision.
Under the coordination of benefits provision of this Plan, the amount normally reimbursed under this Plan
is reduced to take into account payments made by "other plans".
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When this and another health expenses coverage plan applies, the order in which the various plans will pay
benefits must be figured. This will be done as follows using the first rule that applies:
1. A plan with no rules for coordination with other benefits will be deemed to pay its benefits before a
plan which contains such rules.
2. A plan which covers a person other than as a dependent will be deemed to pay its benefits before a plan
which covers the person as a dependent; except that if the person is also a Medicare beneficiary and as
a result of the Social Security Act of 1965, as amended, Medicare is:
The benefits of a plan which covers the person as a dependent will be determined before the benefits of a
plan which:
3. Except in the case of a dependent child whose parents are divorced or separated; the plan which covers
the person as a dependent of a person whose birthday comes first in a calendar year will be primary to
the plan which covers the person as a dependent of a person whose birthday comes later in that
calendar year. If both parents have the same birthday, the benefits of a plan which covered one parent
longer are determined before those of a plan which covered the other parent for a shorter period of
time.
If the other plan does not have the rule described in this provision (3) but instead has a rule based on the
gender of the parent and if, as a result, the plans do not agree on the order of benefits, the rule in the other
plan will determine the order of benefits.
g. If there is a court decree which states that the parents shall share joint custody of a dependent child,
without stating that one of the parents is responsible for the health care expenses of the child, the
order of benefit determination rules specified in (3) above will apply.
h. If there is a court decree which makes one parent financially responsible for the medical, dental or
other health care expenses of such child, the benefits of a plan which covers the child as a
dependent of such parent will be determined before the benefits of any other plan which covers the
child as a dependent child.
i. If there is not such a court decree:
If the parent with custody of the child has not remarried, the benefits of a plan which covers the child as a
dependent of the parent with custody of the child will be determined before the benefits of a plan which
covers the child as a dependent of the parent without custody.
If the parent with custody of the child has remarried, the benefits of a plan which covers the child as a
child as a dependent of the stepparent. The benefits of a plan which covers that child as a dependent of the
stepparent will be determined before the benefits of a plan which covers that child as a dependent of the
parent without custody.
5. If 1, 2, 3 and 4 above do not establish an order of payment, the plan under which the person has been
covered for the longest will be deemed to pay its benefits first; except that:
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 the dependent of such person;
 a dependent of such person.
The benefits of a plan which covers the person on whose expenses claim is based under a right of
continuation pursuant to federal or state law shall be determined after the benefits of any other plan which
covers the person other than under such right of continuation.
The general rule is that the benefits otherwise payable under this Plan for all expenses incurred in a
calendar year will be reduced by all "other plan" benefits payable for those expenses. When the
coordination of benefits rules of this Plan and an "other plan" both agree that this Plan determines its
benefits before such other plan, the benefits of the other plan will be ignored in applying the general rule
above to the claim involved.
In order to administer this provision, Aetna can release or obtain data. Aetna can also make or recover
payments.
When this provision operates to reduce the total amount of benefits otherwise payable as to a person
covered under this Plan during a calendar year, each benefit that would be payable in the absence of this
provision will be reduced proportionately. Such reduced amount will be charged against any applicable
benefit limit of this Plan.
Other Plan



Group insurance.
Any other type of coverage for persons in a group. This includes plans that are insured and those that
are not.
No-fault auto insurance required by law and provided on other than a group basis. Only the level of
benefits required by the law will be counted.
270
When You Have Medicare Coverage
Effect of Medicare
Effect of Medicare
 is covered under it;
 is not covered under it because of:
 All health expenses covered under this Plan will be reduced by any Medicare benefits available for
those expenses. This will be done before the health benefits of this Plan are figured.
 Charges used to satisfy a person's Part B deductible under Medicare will be applied under this Plan in
the order received by Aetna. Two or more charges received at the same time will be applied starting
with the largest first.
 Medicare benefits will be taken into account for any person while he or she is eligible for Medicare.
This will be done whether or not he or she is entitled to Medicare benefits.
 Any rule for coordinating "other plan" benefits with those under this Plan will be applied after this
Plan's benefits have been figured under the above rules. Allowable Expenses will be reduced by any
Medicare benefits available for those expenses.
Coverage will not be changed at any time when your Employer's compliance with federal law requires this
Plan's benefits for a person to be figured before benefits are figured under Medicare.
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General Provisions
Type of Coverage
Coverage under the plan is non-occupational. Only non-occupational accidental injuries and
non-occupational illnesses are covered. The plan covers charges made for services and supplies only
while the person is covered under the plan.
Aetna will have the right and opportunity to examine and evaluate any person who is the basis of any
claim at all reasonable times while a claim is pending or under review. This will be done at no cost to you.
Legal Action
No legal action can be brought to recover payment under any benefit after 3 years from the deadline for
filing claims.
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



This Benefit Description applies to coverage only, and does not restrict your ability to receive health
care services that are not, or might not be, covered.
You cannot receive multiple coverage under the plan because you are connected with more than one
employer.
In the event of a misstatement of any fact affecting your coverage under the plan, the true facts will be
used to determine the coverage in force.
This document describes the main features of the plan. If you have any questions about the terms of the
plan or about the proper payment of benefits, contact your employer or Aetna.
The plan may be changed or discontinued with respect to your coverage.
Assignments
Coverage and your rights under this plan may not be assigned. A direction to pay a provider is not an
assignment of any right under this plan or of any legal or equitable right to institute any court proceeding.
Misstatements
Aetna’s failure to implement or insist upon compliance with any provision of this plan at any given time
or times, shall not constitute a waiver of Aetna’s right to implement or insist upon compliance with that
provision at any other time or times.
Fraudulent misstatements in connection with any claim or application for coverage may result in
termination of all coverage under this plan.
Health Coverage
If a benefit payment is made by the Plan, to or on your behalf, which exceeds the benefit amount that you
are entitled to receive, the Plan has the right:
 To require the return of the overpayment; or
 To reduce by the amount of the overpayment, any future benefit payment made to or on behalf of that
person or another person in his or her family.
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Reporting of Claims
A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss.
Your employer has claim forms.
If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still
be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health
benefits will not be covered if they are filed more than 2 years after the deadline.
Payment of Benefits
Benefits will be paid as soon as the necessary proof to support the claim is received. Written proof must be
provided for all benefits.
All covered health benefits are payable to you. However, Aetna has the right to pay any health benefits to
the service provider. This will be done unless you have told Aetna otherwise by the time you file the
claim.
The Plan may pay up to $1,000 of any other benefit to any of your relatives whom it believes fairly entitled
to it. This can be done if the benefit is payable to you and you are a minor or not able to give a valid
release.
Records of Expenses
Very important are:
 Names of dentists who furnish services.
 Dates expenses are incurred.
 Copies of all bills and receipts.
Contacting Aetna
If you have questions, comments or concerns about your benefits or coverage, or if you are required to
submit information to Aetna, you may contact Aetna’s Home Office at:
Hartford, CT 06156
You may also use Aetna’s toll free Member Services phone number on your ID card or visit Aetna’s web
site at www.aetna.com.
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Discount Programs
From time to time, we may offer, provide, or arrange for discount arrangements or special rates from
certain service providers such as pharmacies, optometrists, dentists, alternative medicine, wellness and
healthy living providers to you under this plan. Some of these arrangements may be made available
through third parties who may make payments to Aetna in exchange for making these services available.
The third party service providers are independent contractors and are solely responsible to you for the
provision of any such goods and/or services. We reserve the right to modify or discontinue such
arrangements at any time. These discount arrangements are not insurance. There are no benefits payable to
you nor do we compensate providers for services they may render through discount arrangements.
Incentives
In order to encourage you to access certain medical services when deemed appropriate by you in
consultation with your physician or other service providers, we may, from time to time, offer to waive or
reduce a member’s copayment, payment percentage, and/or a deductible otherwise required under the
plan or offer coupons or other financial incentives. We have the right to determine the amount and
duration of any waiver, reduction, coupon, or financial incentive and to limit the covered persons to whom
these arrangements are available.
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Glossary
In this section, you will find definitions for the words and phrases that appear in bold type throughout the
text of the Dental PPO Benefit Description.
Accident
This means a sudden; unexpected; and unforeseen; identifiable occurrence or event producing, at the time,
objective symptoms of a bodily injury. The accident must occur while the person is covered under this
Contract. The occurrence or event must be definite as to time and place. It must not be due to, or
contributed by, an illness or disease of any kind.
Aetna
Aetna Life Insurance Company, an affiliate, or a third party vendor under contract with Aetna.
Copay or Copayment
The specific dollar amount or percentage required to be paid by you or on your behalf. The plan includes
various copayments, and these copayment amounts or percentages are specified in the Schedule of
Benefits.
Cosmetic
Services or supplies that alter, improve or enhance appearance.
Covered Expenses
Medical, dental, vision or hearing services and supplies shown as covered under this Benefit Description.
Deductible
The part of your covered expenses you pay before the plan starts to pay benefits. Additional information
regarding deductibles and deductible amounts can be found in the Schedule of Benefits.
Dental Provider
This is:
 Any dentist;
 Group;
 Organization;
 Dental facility; or
 Other institution or person
legally qualified to furnish dental services or supplies.
Dental Emergency
Any dental condition that:
 Occurs unexpectedly;
 Requires immediate diagnosis and treatment in order to stabilize the condition; and
 Is characterized by symptoms such as severe pain and bleeding.
Dentist
A legally qualified dentist, or a physician licensed to do the dental work he or she performs.
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Directory
A listing of all network providers serving the class of employees to which you belong. The
contractholder will give you a copy of this directory. Network provider information is also available
through Aetna's online provider directory, DocFind®.
Experimental or Investigational
Except as provided for under the Clinical Trials benefit provision, a drug, a device, a procedure, or
treatment will be determined to be experimental or investigational if:





There is not enough outcomes data available from controlled clinical trials published in the
peer-reviewed literature to substantiate its safety and effectiveness for the illness or injury involved;
or
Approval required by the FDA has not been granted for marketing; or
A recognized national medical or dental society or regulatory agency has determined, in writing, that it
is experimental or investigational, or for research purposes; or
It is a type of drug, device or treatment that is the subject of a Phase I or Phase II clinical trial or the
experimental or research arm of a Phase III clinical trial, using the definition of “phases” indicated in
regulations and other official actions and publications of the FDA and Department of Health and
Human Services; or
The written protocol or protocols used by the treating facility, or the protocol or protocols of any other
facility studying substantially the same:
 drug;
 device;
 procedure; or
 treatment.
It also includes the written informed consent used by:
 the treating facility; or
 by another facility studying the same:
 drug;
 device;
 procedure; or
 treatment
that states that it is experimental or investigational, or for research purposes.
Hospital
An institution that:
 Is primarily engaged in providing, on its premises, inpatient medical, surgical and diagnostic services;
 Is supervised by a staff of physicians;
 Provides twenty-four (24) hour-a-day R.N. service,
 Charges patients for its services;
 Is operating in accordance with the laws of the jurisdiction in which it is located; and
 Does not meet all of the requirements above, but does meet the requirements of the jurisdiction in
which it operates for licensing as a hospital and is accredited as a hospital by the Joint Commission on
the Accreditation of Healthcare Organizations.
In no event does hospital include a convalescent nursing home or any institution or part of one which is
used principally as a convalescent facility, rest facility, nursing facility, facility for the aged, extended care
276
facility, intermediate care facility, skilled nursing facility, hospice, rehabilitative hospital or facility
primarily for rehabilitative or custodial services.
Illness
A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory
findings peculiar to the findings set the condition apart as an abnormal entity differing from other normal
or pathological body states.
Injury
An accidental bodily injury that is the sole and direct result of:
 An unexpected or reasonably unforeseen occurrence or event; or
 The reasonable unforeseeable consequences of a voluntary act by the person.
 An act or event must be definite as to time and place.
Jaw Joint Disorder
This is:
 A Temporomandibular Joint (TMJ) dysfunction or any alike disorder of the jaw joint; or
 A Myofacial Pain Dysfunction (MPD); or
 Any alike disorder in the relationship of the jaw joint and the related muscles and nerves.
Lifetime Maximum
This is the most the plan will pay for covered expenses incurred by any one covered person in their
lifetime.
Medically Necessary or Medical Necessity
These are health care or dental services, and supplies or prescription drugs that a physician, other health
care provider or dental provider, exercising prudent clinical judgment, would give to a patient for the
purpose of:
 preventing;
 evaluating;
 diagnosing; or
 treating:
 an illness;
 an injury;
 a disease; or
 its symptoms.
The provision of the service, supply or prescription drug must be:
e) In accordance with generally accepted standards of medical or dental practice;
f) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective
for the patient's illness, injury or disease; and
g) Not mostly for the convenience of the patient, physician, other health care or dental provider; and
h) And do not cost more than an alternative service or sequence of services at least as likely to produce
the same therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness,
injury, or disease.
For these purposes “generally accepted standards of medical or dental practice” means standards that are
based on credible scientific evidence published in peer-reviewed literature. They must be generally
recognized by the relevant medical or dental community. Otherwise, the standards are consistent with
277
physician or dental specialty society recommendations. They must be consistent with the views of
physicians or dentists practicing in relevant clinical areas and any other relevant factors.
Negotiated Charge
The maximum charge a network provider has agreed to make as to any service or supply for the purpose
of the benefits under this plan.
Network Provider
A dental provider who has contracted to furnish services or supplies for this plan; but only if the provider
is, with Aetna's consent, included in the directory as a network provider for:
 The service or supply involved; and
 The class of employees to which you belong.
Network Service(s) or Supply(ies)
 Furnished by a network provider
Non-Occupational Illness
A non-occupational illness is an illness that does not:
 Result in any way from an illness that does.
An illness will be deemed to be non-occupational regardless of cause if proof is furnished that the person:
 Is covered under any type of workers' compensation law; and
 Is not covered for that illness under such law.
Non-Occupational Injury
A non-occupational injury is an accidental bodily injury that does not:
 Result in any way from an injury which does.
Occupational Injury or Occupational Illness
An injury or illness that:
 Arises out of (or in the course of) any activity in connection with employment or self-employment
whether or not on a full time basis; or
 Results in any way from an injury or illness that does.
Occurrence
This means a period of disease or injury. An occurrence ends when 60 consecutive days have passed
during which the covered person:
 Receives no medical treatment; services; or supplies; for a disease or injury; and
 Neither takes any medication, nor has any medication prescribed, for a disease or injury.
This is any:
 Medical service or supply; or
 Dental service or supply;
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furnished to prevent or to diagnose or to correct a misalignment:
 Of the teeth; or
 Of the bite; or
 Of the jaws or jaw joint relationship;
whether or not for the purpose of relieving pain.
Out-of-Network Service(s) and Supply(ies)
 Furnished by an out-of network provider.
Out-of-Network Provider
A dental provider who has not contracted with Aetna, an affiliate, or a third party vendor, to furnish
services or supplies for this plan.
Payment Percentage
Payment percentage is both the percentage of covered expenses that the plan pays, and the percentage of
covered expenses that you pay. The percentage that the plan pays is referred to as the “plan payment
percentage,” and varies by the type of expense. Please refer to the Schedule of Benefits for specific
information on payment percentage amounts.
Physician
A duly licensed member of a medical profession who:
 Has an M.D. or D.O. degree;
 Is properly licensed or certified to provide medical care under the laws of the jurisdiction where the
individual practices; and
 Provides medical services which are within the scope of his or her license or certificate.
This also includes a health professional who:
 Is properly licensed or certified to provide medical care under the laws of the jurisdiction where he or
she practices;
 Provides medical services which are within the scope of his or her license or certificate;
 Under applicable insurance law is considered a "physician" for purposes of this coverage;
 Has the medical training and clinical expertise suitable to treat your condition;
 Specializes in psychiatry, if your illness or injury is caused, to any extent, by alcohol abuse, substance
abuse or a mental disorder; and
 A physician is not you or related to you.
Precertification or Precertify
A process where Aetna is contacted before certain services are provided, such as hospitalization or
outpatient surgery, or prescription drugs are prescribed to determine whether the services being
recommended or the drugs prescribed are considered covered expenses under the plan. It is not a
guarantee that benefits will be payable.
Prescriber
Any physician or dentist, acting within the scope of his or her license, who has the legal authority to write
an order for a prescription drug.
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Prescription
An order for the dispensing of a prescription drug by a prescriber. If it is an oral order, it must be
promptly put in writing by the pharmacy.
Prescription Drug
A drug, biological, or compounded prescription which, by State and Federal Law, may be dispensed only
by prescription and which is required to be labeled "Caution: Federal Law prohibits dispensing without
prescription." This includes:

An injectable drug prescribed to be self-administered or administered by any other person except one
who is acting within his or her capacity as a paid healthcare professional. Covered injectable drugs
include injectable insulin.
Recognized Charge
The covered expense is only that part of a charge which is the recognized charge.
As to dental expenses, the recognized charge for each service or supply is the lesser of:
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
What the provider bills or submits for that service or supply; and
The 90th percentile of the Prevailing Charge Rate;
for the Geographic Area where the service is furnished.
If Aetna has an agreement with a provider (directly, or indirectly through a third party) which sets the rate
that Aetna will pay for a service or supply, then the recognized charge is the rate established in such
agreement.
Aetna may also reduce the recognized charge by applying Aetna Reimbursement Policies. Aetna
Reimbursement Policies address the appropriate billing of services, taking into account factors that are
relevant to the cost of the service such as:
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the duration and complexity of a service;
whether multiple procedures are billed at the same time, but no additional overhead is required;
whether an assistant surgeon is involved and necessary for the service;
if follow up care is included;
whether there are any other characteristics that may modify or make a particular service unique; and
when a charge includes more than one claim line, whether any services described by a claim line are
part of or incidental to the primary service provided.
Aetna Reimbursement Policies are based on Aetna's review of: the policies developed for Medicare; the
generally accepted standards of medical and dental practice, which are based on credible scientific
evidence published in peer-reviewed literature generally recognized by the relevant medical or dental
community or which is otherwise consistent with physician or dental specialty society recommendations;
and the views of physicians and dentists practicing in the relevant clinical areas. Aetna uses a commercial
software package to administer some of these policies.
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As used above, Geographic Area and Prevailing Charge Rates are defined as follows:
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
Geographic Area: This means an expense area grouping defined by the first three digits of the U.S.
Postal Service zip codes. If the volume of charges in a single three digit zip code is sufficient to
produce a statistically valid sample, an expense area is made up of a single three digit zip code. If the
volume of charges is not sufficient to produce a statistically valid sample, two or more three digit zip
codes are grouped to produce a statistically valid sample. When it is necessary to group three digit zip
codes, the grouping never crosses state lines.
Prevailing Charge Rates: These are the rates reported by FAIR Health, a nonprofit company, in their
database. FAIR Health reviews and, if necessary, changes these rates periodically. Aetna updates its
systems with these changes within 180 days after receiving them from FAIR Health.
Important Note
Aetna periodically updates its systems with changes made to the Prevailing Charge Rates.
What this means to you is that the recognized charge is based on the version of the rates that is in use by
Aetna on the date that the service or supply was provided.
Additional Information
Aetna's website aetna.com may contain additional information which may help you determine the cost of
a service or supply. Log on to Aetna Navigator to access the "Estimate the Cost of Care" feature. Within
this feature, view our "Cost of Care" and "Member Payment Estimator" tools, or contact our Customer
Service Department for assistance.
R.N.
A registered nurse.
An institution that meets all of the following requirements:
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

It is licensed to provide, and does provide, the following on an inpatient basis for persons convalescing from
illness or injury:
 Professional nursing care by an R.N., or by a L.P.N. directed by a full-time R.N.; and
 Physical restoration services to help patients to meet a goal of self-care in daily living activities.
Provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N.
Is supervised full-time by a physician or an R.N.
Keeps a complete medical record on each patient.
Has a utilization review plan.
Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for mental retardates, for custodial or
educational care, or for care of mental disorders.
Charges patients for its services.
An institution or a distinct part of an institution that meets all of the following requirements:
 It is licensed or approved under state or local law.
 Is primarily engaged in providing skilled nursing care and related services for residents who require
medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.
Qualifies as a skilled nursing facility under Medicare or as an institution accredited by:
 The Joint Commission on Accreditation of Health Care Organizations;
 The Bureau of Hospitals of the American Osteopathic Association; or
 The Commission on the Accreditation of Rehabilitative Facilities
Skilled nursing facilities also include rehabilitation hospitals (all levels of care, e.g. acute) and portions of a
hospital designated for skilled or rehabilitation services.
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Skilled nursing facility does not include:
 Institutions which provide only:
 Minimal care;
 Custodial care services;
 Ambulatory; or
 Part-time care services.
 Institutions which primarily provide for the care and treatment of alcoholism, substance abuse or
mental disorders.
Specialist
A physician who practices in any generally accepted medical or surgical sub-specialty.
Specialist Dentist
Any dentist who, by virtue of advanced training is board eligible or certified by a Specialty Board as
being qualified to practice in a special field of dentistry.
Specialty Care
Health care services or supplies that require the services of a specialist.
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B.6 DENTAL DMO
Aetna DMO
The Dental Maintenance Organization (DMO) is a prepaid dental health plan. Under the DMO,
each family member must select a personal dentist from the DMO directory of participating
dentists. Each family member may select a different personal dentist. In order to receive benefits,
your personal dentist must perform all initial services. If specialty care is required, your personal
dentist will provide you with a referral to a specialist.
There are no deductibles or annual maximums. The plan typically pays the full cost of preventive
and basic services such as exams, teeth cleanings, X-rays, fillings, and uncomplicated extractions.
Major services are typically covered at a 60% benefit level. Orthodontia benefits are also available
and are typically covered at a 50% benefit level.
The DMO plan is underwritten by Aetna Life Insurance Company, Aetna Health Inc., Aetna
Dental of California Inc. and/or Aetna Dental Inc.
Depending on your location, you may be covered under a DMO plan underwritten by one or more
of the above Aetna group of subsidiary companies. Some states may require different provisions
under the DMO. For complete information, please consult the Benefit Description certificate,
certificate of coverage or evidence of coverage for your respective DMO plan. You can obtain this
certificate from Aetna by contacting 1-877-238-6200.
DMO Availability
The DMO is available in most locations. Please refer to a DMO provider directory available at
www.aetna.com to determine if the DMO is available in your area.
Identification Cards
Each eligible family member will receive an identification card with the personal dentist’s name
and telephone number on the front, and the DMO Employee Hotline telephone number on the
back.
Scheduling Appointments
Once you’ve selected your personal dentist, you can make an appointment exactly as you would
with any other dentist. Simply mention that you are covered under the DMO when you make your
appointment. At the time of your visit, present your DMO identification card.
Emergency Care
In an emergency, you should call your personal dentist, who is available for emergencies 24 hours
a day. If the emergency is after office hours, you should follow the answering service’s
instructions or those on the recorded message. For questions, contact Aetna member services.
Specialist Care
If you need specialty care, you must first see your personal dentist for a specialty referral.
Aetna DMO Schedule of Benefits
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Dental Coverage
Annual deductible
Aetna DMO
None
Annual Plan Maximum
None
Preventive Services
(cleanings, fluoride treatment, bitewing
x-rays, full mouth x-rays)
Dental sealants
100%; two cleanings per year
Basic services
(fillings, extractions, root canal therapy, oral
surgery)
Major services
(crowns, gold restorations, complete/partial
dentures, fixed bridges, implants)
Orthodontia
100%
(molar root canal and oral surgery covered at
60%)
100%
60%
50%
(limited to one course of treatment per person
per lifetime)
Submitting Claims
Most claims are handled by your DMO provider. However, if for any reason you incur expenses
that are eligible for reimbursement, a claim must be submitted to the DMO carrier.
COBRA Continuation
When coverage under the Dental DMO Plan terminates, it cannot be converted to an individual
policy. However, continuation coverage may be available through COBRA if you or your
dependents experience a qualifying event. See the Continuation of Coverage section for details.
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B.7 LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT
INSURANCE
Available Coverage
The life and accident insurance plans offer you and your family the opportunity to have financial
protection when you may need it most. The life insurance plans are administered by Cigna.



Life Insurance provides your beneficiary with a benefit in the event of your death.
Accidental Death and Dismemberment (AD&D) Insurance provides an additional benefit if
you die or suffer a serious injury as result of an accident (e.g., lose a limb, become paralyzed, lose
your hearing, speech or sight).
Dependent Life and Dependent AD&D Insurance provides coverage for your spouse, domestic
partner and eligible dependent children.
Company-Provided Life and AD&D Insurance
SPE provides Life and Accidental Death and Dismemberment (AD&D) insurance at no cost to you
equal to one times your base salary, to a maximum of $1,000,000 rounded up to the next higher $1,000.
Supplemental Life and AD&D Insurance
You can choose to purchase Supplemental Life and AD&D Insurance up to eight (8) times your base
salary rounded up to the next higher $1,000, up to a maximum of $1,500,000. The cost of
Supplemental Life Insurance coverage is based on your age, salary, and the amount of coverage you
have selected. Deductions will be withheld from your paycheck on an after-tax basis.
Evidence of Insurability
You must submit an Evidence of Insurability (EOI) form and receive insurance company approval
under the following circumstances:
 If you elect Supplemental Life Insurance Coverage of greater than $500,000
 If you elected Supplemental Life Insurance when you first became eligible and later want
to increase your Supplemental Life Insurance coverage by more than one times your
annual salary
 During open enrollment, if you increase your coverage more than one times your base
salary or $500,000
 You have a qualified status change, e.g., marriage, divorce, birth of a child and you elect to
increase your coverage by more than one times your base salary or $500,000
Contact SPE Benefits Connection if you have questions about EOI.
Mid-Year Salary and Contribution Rate Changes
If your base salary increases during the year your coverage amount for both Basic and Supplemental
Life Insurance coverage and your employee contribution for supplemental coverage will be based on
your salary on September 1st of that year. Your coverage will increase accordingly effective January
1st of the following year, subject to the coverage maximums described above. The coverage amounts
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and employee contributions will be reduced in a similar fashion if your earnings decrease. Your
premiums will be based on your age as of 1/1 of the benefit plan year.
If You Become Totally Disabled
Basic Life Insurance: If you cease to be actively at work due to total disability and you are
receiving disability payments from an SPE disability plan, your Basic Life Insurance will be
continued by SPE for up to 6 months from your date of disability. If you do not return to active
employment when your Basic Life Insurance benefits would otherwise end, you may have the
right to convert your coverage to an individual policy (see Conversion Privilege for Basic and
Supplemental Life).
Supplemental Life Insurance: If you remain totally disabled for more than six (6) months, you
may be eligible to apply for Waiver of Premium for the Supplemental Life Insurance amount in
force just prior to your disability. To qualify for Waiver of Premium, you must meet the following
criteria:
 Your total disability must start after you have been covered for Supplemental Life benefits
for at least six (6) months, and
 Your total disability began before age 60.
If you would like to apply for Waiver of Premium, you must request a Waiver of Premium
application from Cigna at the six-month mark out on disability. The application should be
completed and submitted to Cigna within nine (9) months of continuous disability. If Cigna
approves your application for Waiver of Premium, your Supplemental Life Insurance will
continue at no cost to you until the earlier of:
 The date you are no longer totally disabled; or,
 The date you do not give Cigna proof of total disability when required
While you are on Waiver of Premium, Cigna will periodically (not more than once per year) ask
you to submit proof that you continue to be totally disabled. Cigna may require you to have a
physical exam by doctors of their choice and at their expense. Also, while on Waiver of Premium,
you may experience an increase to imputed income as described in a subsequent section.
If you do not return to active employment when your Supplemental Life Insurance benefits would
otherwise end, you may have the right to convert your coverage to an individual policy (see
Conversion Privilege for Basic and Supplemental Life).
Accelerated Benefits
If you become terminally ill while covered under Basic Life Insurance (and, if applicable,
Supplemental Life Insurance) you may apply to have a portion of your coverage amount paid to
you one time while you are living. If approved by the Cigna, Accelerated Benefits proceeds can be
up to 80% of the amount of life insurance in force on the date the Claims Administrator receives
proof of your terminal illness, up to a maximum of $500,000. On your death, the benefits that
would otherwise have been payable will be reduced by the amount of the Accelerated Benefits
proceeds. For purposes of this benefit, terminally ill means a life expectancy of 6 months or less as
certified by a doctor. To apply for Accelerated Benefits, contact SPE Benefits Connection.
Payment of Accelerated Benefits is subject to approval by Cigna.
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Beneficiary Designation
You must name a beneficiary at the time you become a plan participant. You may name a new
beneficiary at any time online at https://benefits.spe.sony.com. If you do not name a beneficiary or
if your beneficiary is not living at the time of your death and there is no contingent (secondary)
beneficiary, benefits will be paid in the following order:
 Your spouse;
 Your child(ren) in equal shares;
 Your surviving parents;
 Your siblings in equal shares;
 Your estate.
Assignment Rights
The rights provided to you by the Life and AD&D Insurance Plan are owned by you, unless:


You have previously assigned these rights to someone else (called the “assignee”); or
You assign your rights under the plan to an assignee.
The plan will recognize an assignee as the owner of the rights assigned only if:


The assignment is in writing, signed by you, and acceptable to Cigna; and
A signed or certified copy of the written assignment has been received and registered by Cigna.
SPE or Cigna assumes no responsibility for the validity of any assignment. You are responsible to see
the assignment is legal in your state and that it accomplishes the goals that you intend.
Imputed Income
The value of Basic and Supplemental Life Insurance coverage in excess of $50,000, which is pad
by SPE, is taxable income to you. This tax liability is called “imputed income” and is included as
taxable income on your paycheck and is reported on your W-2 form at the end of the year.
The amount of your imputed income (if any) is based on your age, amount of coverage in excess of
$50,000 and the value of such coverage, as determined in accordance with the IRS Imputed
Income Schedule.
Suicide Exclusion for Supplemental Life Insurance
Supplemental Life Insurance benefits will not be paid to your beneficiary if you commit suicide,
while sane or insane, within two (2) years after the effective date of your Supplemental Life
Insurance coverage and/or the effective date of any increase in the amount of your supplemental
life benefits. If this exclusion applies, your beneficiary will be reimbursed an amount equal to any
contributions you paid for the excluded coverage, without interest.
Conversion Privilege for Basic and Supplemental Life
Upon termination of your coverage, you may be eligible to convert your Basic and Supplemental
Life Insurance coverage to an individual policy by completing a conversion application (available
from SPE Benefits Connection). You may convert the full amount of your coverage or a portion
thereof, without having to furnish EOI. Cigna will determine the type of individual policies (such
as whole life) available to you and the cost; term life insurance is not offered. The application must
be submitted to the Claims Administrator within the 31-day period from the date coverage ends, or
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if later, 15 days from the date the conversion notice is given if the notice was given 15 days prior to
the date coverage was terminated. In no event will the conversion period extend beyond 90 days
from the date coverage was terminated. If you die during this 31-day period, your Basic Life
Insurance and, if applicable, your Supplemental Life Insurance amount will be paid, whether or
not you have applied for an individual policy.
Portability Option for Supplemental Life Insurance
The portability option allows you to continue the full amount of your Supplemental Life Insurance
or a portion thereof, on a group basis through Cigna following termination of your coverage. If you
choose this option, you will be required to complete a Portability Application, subject to approval
from the insurance company. Your Ported Policy will terminate at age 80, at which time you will
be provided an option to apply for Conversion. Rate information is provided on the portability
application form (available from SPE Benefits Connection). Application for portability must be
made within the 31-day period from the date coverage ends.
Schedule of AD&D Benefits
Depending on the nature of your injury, you or your beneficiary will receive a percentage of the
AD&D coverage amount. For benefits to be payable:


Death or the loss suffered must be the direct result of the accidental injury and from no other cause;
and
Death or the loss must occur within 365 days of the accident.
You or your beneficiary will receive a percentage of your total AD&D benefit for these losses:
Loss
Life
Coma
Both hands or both feet
Sight in both eyes
One hand and one foot
One hand and sight in one eye
One foot and sight in one eye
Speech and hearing
Quadriplegia
Paraplegia
One hand or one foot
Sight of one eye
Speech or hearing in both ears
Hemiplegia
Thumb and index finger of the same hand
Percentage of the AD&D Coverage
Amount Paid
100%*
1% of principal sum for 11 months; 100% of
principal sum at the beginning of the 12th
month
100%
100%
100%
100%
100%
100%
100%
75%
50%
50%
50%
50%
25%
*Paid in addition to Employee Life Insurance.
Loss of a hand or foot means that the hand or foot is completely severed at or above the wrist or ankle
joint.
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Loss of sight means total irrevocable loss of sight.
The maximum benefit the plan will pay for any combination of covered losses is the full amount.
Situations Not Covered by AD&D Insurance
AD&D Insurance benefits are paid for losses caused only by accidents. Also, your AD&D Insurance
does not cover any accidental loss caused by:








Suicide and intentionally self-inflected injury;
Active participation in a riot;
Participation in a felony;
Drug addiction;
Travel or flight in any vehicle or device for aerial navigation including boarding or alighting from
it while:
- It is being used for test or experimental purposes;
- You are operating, learning to operate, or serving as a member of the crew;
- It is being operated by or for or under the direction of any military authority.
This exclusion does not apply to:
- Transport type aircraft operated by the Military Airlift Command of the United States; or
- Similar air transport service of any other country;
Travel or flight in any aircraft or device for aerial navigation, including boarding or alighting form
it, owned or leased by or on behalf of SPE;
Disease of the body or diagnostic, medical or surgical treatment or mental disorder s set forth in the
latest edition of the Diagnostic and Statistical Manual of Mental Disorders; or
War, declared or undeclared, or any act of war.
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Dependent Life Insurance
You can also choose to purchase Dependent Life Insurance coverage for your spouse and eligible
children.
Eligible Dependents
You can elect Dependent Life Insurance coverage for:
 Your spouse or domestic partner
 Your dependent child(ren) to age 26.
Dependents may be asked to provide proof of dependent eligibility during SPE’s dependent audit
and/or at the time of a claim. Failure to provide proof may result in a claim denial.
Coverage Options
You may choose Dependent Life coverage for your spouse/domestic partner and /or your
dependent children.
Spouse/domestic partner life insurance is available in the following amounts:





$10,000
$25,000
$50,000
$100,000
$250,000
You May Elect Child Life Insurance In The Amount Of $10,000 Or $20,000.
Cost of Coverage
Contributions are made on an after-tax basis, based on the rates established each plan year. Spouse
rates are determined based on the age of your spouse/domestic partner coverage and the amount of
coverage you select. Child Life coverage has a flat rate for each option regardless of the number of
children covered. You pay the full cost of Dependent Life Insurance coverage with after-tax
deductions.
Spouse/domestic partner life insurance will always be subject to Evident of Insurability (EOI).
Child dependent life insurance is guaranteed issue and not subject to EOI.
Accelerated Death Benefits
If you have elected Spouse Dependent Life Insurance and your spouse becomes terminally ill
while covered, you may apply to have a portion of the coverage amount paid to you while your
spouse is living.
If approved by Cigna, Accelerated Benefits proceeds can be up to 80% of the amount of life
insurance in force on the date the Claims Administrator receives proof of terminal illness. Upon
death, the benefits that would otherwise have been payable will be reduced by the amount of the
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Accelerated Benefits proceeds. For purposes of this benefit, terminally ill means a life expectancy
of 6 months or less as certified by a doctor.
To apply for Accelerated Benefits, contact SPE Benefits Connection. Payment of Accelerated
Benefits is subject to approval by Cigna.
Suicide Exclusion
Dependent Life Insurance benefits will not be paid if a covered dependent commits suicide, while
sane or insane, within two (2) years after the effective date of dependent life coverage and/or the
effective date of any increase in the amount of your dependent life coverage. If this exclusion
applies, you or your contingent beneficiary will be reimbursed an amount equal to any
contributions paid for the excluded coverage, without interest, if there are no other surviving
eligible dependents.
Beneficiary Designation
Under SPE’s Dependent Life Insurance Plan, you as the employee will be the sole beneficiary. You
may also designate a contingent beneficiary in the event that you are not living at the time of the
dependent’s death.
Filing a Claim
Claim forms needed to file for benefits can be requested from SPE Benefits Connection. The
instructions on the claim form should be followed carefully to expedite the processing of the claim.
Completed claim forms accompanied by an original certified death certificate should be submitted
to Cigna. When the claim has been processed, you or, if applicable, your beneficiary will be
notified of the benefits paid. If any benefits have been denied, you or, if applicable, your
beneficiary will receive a written explanation.
Imputed Income
Under the Internal Revenue Code, the value of Dependent Life Insurance, in the amounts offered by
SPE, may be taxable income to you. This tax liability is called “imputed income” and is included as an
addition to your paycheck and reported on your W-2 form at the end of the calendar year. The amount
of imputed income (if any) is equal to the difference between the deemed cost of the dependent life
insurance coverage, as determined by the IRS Imputed Income Schedule and the amount that you pay
for the insurance (if less).
Conversion
If you cease to cover your dependent(s) due to termination of your employment, your loss of
eligibility for benefits, your death, your retirement, or your dependents’ loss of eligibility (e.g. a
non-handicapped child who turns age 26), your dependent may convert this coverage to an
individual life insurance policy without providing EOI. A conversion application can be obtained
from SPE Benefits Connection. Cigna will determine the type of individual policies (such as whole
life) available to you and the cost; term life insurance is not offered. The application must be
submitted to the Claims Administrator within the 31-day period from the date coverage ends, or if
later, 15 days from the date the conversion notice is given if the notice was given 15 days prior to
the date coverage was terminated. In no event will the conversion period extend beyond 90 days
from the date coverage was terminated.
Portability Option
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The portability option allows you to continue Dependent Life Insurance for your spouse/domestic
partner and/or children on a group basis through Cigna following eligible termination of coverage
due to your:
 Voluntary termination of employment
 Retirement
 Dismissal from employment
 Change in employee class resulting in a termination of benefits.
Applications must be submitted to Cigna within 31 days after the coverage ends.
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B.8 BUSINESS TRAVEL ACCIDENT INSURANCE
How the Plan Works
SPE automatically provides Business Travel Accident Insurance equal to two times your insured
earnings, subject to a minimum of $100,000 and a maximum of $2,000,000, in the event you should die
in an accident while traveling on company business. That means you have 24-hour protection while
traveling on SPE business away from your ordinary place of work. Your beneficiary designation for
Life and Accidental Death and Dismemberment (AD&D) Insurance applies to this coverage as well.
In addition, the plan pays you a benefit if you should suffer a severe physical loss while traveling on
company business. You’ll receive a percentage of your coverage as follows if the loss is suffered as a
direct result of and within one year of the accident:
Loss
Percentage of the Coverage
Amount Paid
Life
Sight in both eyes
One hand and the sight in one eye
One foot and the sight in one eye
Thumb and index finger on the same hand
100%
100%
100%
100%
100%
100%
50%
25%
Note:
Loss of a hand or foot means completely severed at or above the wrist or ankle joint.
Loss of sight means total irrevocable loss of sight.
The plan covers any accident that occurs while you’re traveling or making a short stay away from your
normal work location and in the course of authorized business for the company. This coverage is
limited to a 250-mile radius of your original business destination and cannot exceed three days of
travel.
Additional coverage includes:


Seatbelt coverage equal to an additional 10% of the benefit to a maximum of $50,000, payable if a
you die as the result of a covered accident which occurs while you are driving or riding in a private
passenger car and it is determined that a seat belt was worn;
Air bag benefit equal to an additional 10% of the benefit to a maximum of $50,000, payable in the
event you die on a business trip and it was determined that the vehicle was equipped with and an air
bag was deployed;
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







Coma benefit equal to 1% of the benefit monthly up to 11 months, payable in the event you lapse
into a coma as a result of an accident that occurred while you were on a business trip;
Psychological benefit equal to an additional 5% of the benefit to a maximum of $50,000, payable if
there is a need for psychological counseling due to injury from a covered accident;
Rehabilitation benefit equal to an additional 5% to a maximum of $50,000, payable in the event
there is a need for a rehabilitation program due to an injury from a covered accident;
AIG Assist with unlimited insured benefits of $100,000 for repatriation and $100,000 for medical
evacuation in the event of a medical emergency whole on company business 100 or more miles
from home;
Everyday commutation coverage to and from work;
Bomb scare or explosion while on the premises of SPE;
Losses incurred due to a criminal act of violence either on or off the premises of SPE;
Hijacking.
The maximum aggregate benefit is $10,000,000 per accident.
The coverage does not apply while commuting between home and place of work, during personal
deviations, or while on company premises.
Coverage starts at the actual start of a trip, whether your trip starts at home, where you work, or another
place, and ends when you arrive at home or work (whichever happens first) or you make a personal
deviation.
Note: If you travel to another city, and expect to work there for more than 60 days, this is considered a
change of your permanent assignment.
Exclusions
The following exclusions apply:









Suicide, or any attempt at suicide while sane or self-destruction, or any attempt at self-destruction
while insane;
Disease of any kind;
Bacterial infections, except pyogenic infection that occurs through an accidental cut or wound;
Hernia of any kind;
Injury sustained while riding as a passenger in any aircraft except as provided in the policy;
Declared or undeclared war or any act thereof, except as provided by the policy;
Service in the military, naval or air service of any country;
Being under the influence of drugs or intoxicants, unless taken under the advice of a physician;
Committing or attempting to commit a felony.
Offset Provision
The accidental death and dismemberment (AD&D) benefits under this plan will be offset by any
benefits paid under a local corporate travel accident policy sponsored by SPE.
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B.9 LONG TERM DISABILITY
How the Plan Works
The Long-Term Disability (LTD) Plan, administered by Liberty Mutual, provides a monthly benefit if
you become totally disabled due to injury or illness and remain disabled for more than 180 days.
If you qualify for LTD coverage after 180 days of short-term disability, the LTD Plan will provide you
with 60% of your insured earnings, for a maximum benefit amount of $20,000 per month. For
information on the SPE Short-Term Disability Plan, go to the Employee Handbook on
www.myspe.sony.com.
You can also elect to purchase an enhanced long-term disability option. The supplemental option
provides an additional 10% of long-term disability coverage for a total of 70% of your basic monthly
earnings, for a combined (Company-paid and supplemental coverage) maximum of $20,000 per
month. The total monthly benefit payable to you from all benefits provided under the LTD Plan cannot
exceed 100% of your basic monthly earnings.
Certain reductions, delays, or exclusions may apply. This SPD contains only a summary of your LTD
coverage. Please refer to the LTD Policy for further details.
Earnings
Basic monthly earnings is your gross monthly rate of earnings in effect immediately prior to the date
disability begins. Basic monthly earnings does not include bonuses, commissions, overtime pay and
extra compensation.
Effect of Changes in Earnings on Benefit Coverage
Once your coverage begins, any increased coverage due to a change in your insured earnings will take
effect as soon as administratively possible, as long as you are an active employee at the time of the
increase. If you are not an active employee at the time of a salary and/or coverage increase, the
coverage amount will increase upon your return to active employment. If your salary is decreased, a
decrease in coverage will take effect immediately but will not affect a payable claim that occurs prior
to the decrease.
Cost of Coverage
SPE provides basic long-term disability coverage at no cost to you. You pay for supplemental
long-term disability coverage on an after-tax basis. By paying for supplemental coverage on an
after-tax basis, all benefits are income tax free. Consult your tax advisor for tax advice for your specific
situation.
Note: Imputed income may apply.
Changing Your Coverage Option
You can change your LTD election at any time during the year.
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B.10 EMPLOYEE ASSISTANCE PLAN (EAP)
Purpose of the EAP
The Employee Assistance Plan (EAP) helps you and your eligible family members deal with a
wide range of life issues. Counselors provide confidential support to help you handle both small
problems and major issues in your life. There’s no charge to you for this service.
How the EAP Works
For advice or counseling, call the EAP and speak to an EAP counselor. The counselor evaluates
the situation with you and recommends a course of action. Recommendations can include:
 On-the-phone discussion with an EAP counselor; and
 A series of face-to-face counseling sessions with an EAP counselor in your area.
 Eight (8) face-to-face counseling sessions per family member, per issue, per year are
available at no cost to you.
If you’re eligible for one-on-one counseling, you need to consider whether to seek additional
assistance outside the EAP when you reach the benefit limit. If you seek assistance outside the plan,
you pay the cost for additional counseling on your own. Certain expenses may be covered through
your health plan. Any psychiatric counseling services that the Medical Plan doesn’t pay for may be
reimbursable from the Health Care Spending Account (if you’re contributing to your account).
The cancellation policy will vary by EAP counselor and SPE will never be charged per sessions.
Note: While covered by the plan, you have certain rights and protections, including the privacy of
your health information.
EAP Benefits
You and your eligible family members are entitled to receive up to eight counseling sessions per
family member per incident each calendar year.
The EAP can help you with:
 Marital and family problems;
 Relationship issues;
 Job pressures;
 Grief and loss;
 Alcohol abuse or drug dependency;
 Financial and credit concerns;
 Emotional problems and stress;
 Child care;
 Elder care;
 Pre-retirement planning;
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


Federal taxpayer problems;
Legal issues and questions; and
Interpersonal conflicts.
EAP services are provided by ComPsych GuidanceResources, an independent firm retained by
SPE to administer the Plan. GuidanceResources has a network of psychologists, social workers,
and marital and family therapists who are trained to deal with a wide variety of personal and
emotional problems.
The EAP is completely confidential. No information about the identity of the caller or the nature of
his or her problem is shared with SPE, unless you provide a written authorization for the EAP to do
so. As indicated above, SPE will not find out about a problem addressed through the EAP unless
you either authorize the EAP to disclose the problem to SPE or independently notify SPE that such
a problem exists.
Financial Services
The FinancialConnect® program offers you unlimited telephone access to certified public
accountants, certified financial planners, and other financial professionals who are trained and
experienced in handling personal financial issues and can offer consulting on issues such as family
budgeting, credit problems, tax questions, investment options, money management and retirement
programs.
Legal Services
The LegalConnect® program provides you with unlimited telephone consultation with attorneys
who are trained and dedicated to providing legal information and assistance to clients with such
issues as divorce, bankruptcy, family law, real estate purchases and wills.
If you need legal representation or extended assistance that cannot be provided by phone,
LegalConnect professionals can provide referrals to local attorneys. You or your family member
will receive a free 30-minute consultation and, thereafter, a 25% reduction in fees for
representation if you choose one of GuidanceResources’s network attorneys.
Family Services
GuidanceResources’s FamilySource® Guidance Specialists offer practical advice through
telephonic consultation, accurate and timely referral information, and educational literature.
Specialists are available to provide assistance on issues such as:
 Finding and evaluating quality daycare
 School selection for the relocating employee
 Planning for your child’s college education
 Understanding programs such as Medicare and Medicaid.
Callers receive detailed resource packages containing accurate referral information on community
resources, available openings in programs, and guidelines for evaluating:
 Daycare centers and after school programs
 Public and private schools and tuition assistance
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

Geriatric assessment clinics
Assisted living and other housing options for the elderly.
GuidanceResources will follow-up to make sure callers have received all the information
necessary to meet their specific needs.
Treatment Not Covered by the EAP
The following treatments aren’t covered by your EAP:
 Treatment for mental retardation (defined as IQ of 70 or below, measured by the Weschler
scales);
 Treatment for autism or learning disabilities;
 Treatment for any condition paid for by Workers’ Compensation or treatment that is
obtained through or required by a government agency; and
 Physical or medical treatment for medical, endocrine, metabolic, or other physiological
disorders including, but not limited to, Pick’s disease, Down syndrome, Parkinson’s
disease, epilepsy, Huntington’s chorea, brain tumor, and Alzheimer’s disease.
Note: Coverage may be provided by your SPE health plan or other health care coverage. In
addition, expenses not covered may be eligible for reimbursement through the Health Care
Spending Account. Even though the medical treatment of a condition is not included under EAP
coverage, the counseling related to your ability or your dependent’s ability to handle the situation
is covered by the EAP.
Also, counseling is not covered in these situations, and you’ll be responsible for payment (unless
coverage is provided by your medical plan) for:
 Counseling by a provider who is not in the EAP network;
 Counseling that exceeds the benefit limits paid for by SPE;
 In-patient counseling, while a patient is hospitalized in a general acute care or acute
psychiatric hospital or other licensed health facility; and
 Involuntary counseling requirements based on the orders of a state or federal judicial
officer or another government official.
How to Contact the EAP
Use of the EAP is entirely voluntary. To contact an EAP counselor at Guidance Resources, call
855-327-7669 (855-EAP-SONY) 24 hours a day, seven days a week or online at
www.guidanceresources.com. If you are a first time visitor to the site, you will be asked to enter
the company Web ID which is EAPSONY.
When Coverage Ends
 Your SPE-provided coverage in your EAP ends at the earliest of the date:
 You leave SPE employment;
 You’re no longer eligible for coverage due to your employment status;
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

You transfer to a position that is not eligible for coverage, or you transfer to a SPE
company that does not offer coverage; and
The EAP ends.
Your family members’ coverage ends when your coverage ends or, if earlier, when your family
member no longer qualifies as a dependent.
All Other Situations
In situations other than retirement when coverage would otherwise end, COBRA provides special
rules that provide the opportunity to continue EAP coverage as part of your medical coverage
continuation for a period of time after coverage would otherwise end.
299
B.11 EXPAT BENEFITS
How the Medical, Dental and Vision Plan Works
The Expat Benefits plan provides Continuous worldwide medical, dental care coverage to eligible
employees virtually anywhere you may travel while residing overseas. While in the US, you have
access to the nation’s largest provider network – the Aetna U.S. Healthcare Preferred Provider
Network with more than 400,000 participating physicians and hospitals.
PPO
In the U.S.
Non-Preferred
OUTSIDE THE
Preferred Benefits
PLAN FEATURES
Benefits
U.S.
(In-Network)
(Out-of-Network)
None
None
$250 per calendar year
Individual Deductible
None
None
Family Deductible
Prior plan credit accrued within the last calendar year from previous
Prior Plan Credit
carrier applies to the current year
$1,000 per calendar $1,000 per calendar
$1,000 per calendar
Individual Coinsurance
year
year
year
Limit
(Include deductibles, coinsurance, copays and Prescription copays for in-network only. Does not include
precertification penalties. Includes Outpatient Prescription Drugs when outside the US)
$3,000 per calendar $3,000 per calendar
$3,000 per calendar
Family Coinsurance Limit
year
year
year
(Include deductibles, coinsurance, copays and Prescription copays for in-network only. Does not include
precertification penalties. Includes Outpatient Prescription Drugs when outside the US)
Unlimited
Lifetime Maximum
Member Payment Percentages
Hospital Services
20%
20%
40% after deductible
Inpatient
20%
20%
Outpatient
The institution's semiprivate rate.
Private Room Limit
No Penalty
No Penalty
$300
Pre-certification Penalty
To avoid penalties and/or benefit reductions for non-preferred benefits received in the U.S., contact the
service center to determine if precertification is needed for a procedure.
20%
20%
Non-Emergency Use of the
Emergency Room
20%
20% after $150 copay 20% after $150 copay
Emergency Room
20%
20%
Non-Urgent Use of Urgent
Care Provider
20%
20%
Urgent Care
Physician Services
20%
20%
Physician Office Visit
20%
20%
Specialist Office Visit
20%
20%
Allergy Testing and
Treatment
300
Allergy Serum and Injection 20%
20%
PPO
PLAN FEATURES
OUTSIDE THE
U.S.
Mental Health Services
20%
Mental Health Inpatient
Coverage
Unlimited days per calendar year
20%
Mental Health Outpatient
Coverage
Unlimited visits per calendar year
Alcohol/Drug Abuse Services
20%
Substance Abuse Inpatient
Coverage
Unlimited days per calendar year
Substance Abuse Outpatient 20%
Coverage
Unlimited visits per calendar year
Prescription Drug Coverage
20%
Generic Drugs
(365 day maximum supply)
Brand Name Drugs
(365 day maximum supply)
20%
In the U.S.
Non-Preferred
Preferred Benefits
Benefits
(In-Network)
(Out-of-Network)
20%
20%
20%
20%
20% per one month
supply
(includes Mail Order
Drugs)
20% per one month
supply
(includes Mail Order
Drugs)
Other Services
No Charge
No Charge
No Charge
Global Emergency
Assistance Program
($500,000 calendar year
maximum)
Included
Included
Included
International Employee
Assistance Program (IEAP)
Includes up to 5 counseling sessions per issue per year per enrolled member. Access benefits by calling
the member service number on ID card: 800-231-7729 or collect 813-775-0190. Services include:
Cultural adjustment assistance, Marital/Family Stress, Child care and behavioral concerns, Social
adaptation needs, Alcohol/Substance Abuse, Work/Life Balance and Depression.
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PPO
PLAN FEATURES
OUTSIDE THE U.S.
In the U.S.
Non-Preferred
Preferred Benefits
Benefits
(In-Network)
(Out-of-Network)
Wellness Benefits
Routine Children Physical
No charge
No charge
No charge
Exams
7 exams in the first 12 months of life, 3 exams in the second 12 months of life, 3 exams in the third 12
months of life, 1 exam per 12 months thereafter to age 22 (includes immunizations)
Routine Adult Physical
No charge
No charge
No charge
Exams
Adults age 22+ & -65: 1 exam/24 months Adults age 65+: 1 exam/12 months (includes immunizations)
Routine Gynecological
No charge
No charge
No charge
Exams
Includes 1 exam and pap smear per calendar year
No charge
No charge
No charge
Mammograms
(Unlimited visits per
calendar year)
Prostate Specific Antigen
No charge
No charge
No charge
(PSA)
Includes 1 PSA per calendar year for males 40+
Digital Rectal Exam
No charge
No charge
No charge
(DRE)
Includes 1 DRE per calendar year for males 40+
No charge
No charge
No charge
Cancer Screening
Includes 1 flex sigmoid and double barium contrast every 5 years; and at age 50+ 1 colonoscopy every 10
years
20%
No charge
40%
Routine Hearing Exam
Includes one routine exam every 24 months.
20%
20%
Hearing Aids
1 hearing aid per ear to $1,000 maximum per ear every 3 years for child to age 24
Vision Care
20%
No charge
40%
Routine Eye Exam
(Covered under medical) Includes one routine exam every 24 months
No Charge up to $100 No Charge up to $100 No Charge up to $100
Vision Care Supplies
maximum
maximum
maximum
Scheduled maximums apply every 24 months
302
PPO
PLAN FEATURES
OUTSIDE THE U.S.
In the U.S.
Non-Preferred
Preferred Benefits
Benefits
(In-Network)
(Out-of-Network)
Other Services
No charge
No charge
No charge
Travel Immunizations
20%
20%
TMJ
($1,000 lifetime maximum)
No charge
No charge
No charge
Hair Prosthesis
($500 calendar year
maximum)
20%
20%
Bereavement Counseling
20%
20%
Nutritional Evaluations
(3 visits per calendar year)
20%
20%
(120 Days per calendar
year)
20%
20%
Hospice Care Facility
Inpatient
(Unlimited lifetime
maximum)
20%
20%
Hospice Care Facility
Outpatient
(Unlimited lifetime
maximum)
20%
20%
Home Health Care
(120 visits per calendar year
combined, includes Private
Duty Nursing)
20%
Spinal Disorder Treatment 20%
(20 visits per calendar year)
20%
Short-Term Rehabilitation 20%
(Includes coverage for Occupational, Physical and Speech Therapies; 60 combined maximum visits per
calendar year)
20%
20%
Diagnostic Outpatient
X-ray
20%
Diagnostic Outpatient Lab 20%
20%
20%
Durable Medical
Equipment
(Unlimited calendar year
maximum)
20%
20%
Bariatric Surgery
($10,000 per lifetime)
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20%
20%
Base Infertility Services
(Base plan coverage includes coverage limited to the testing and treatment of underlying condition)
Autism Member cost
Autism covered same as any other expense.
sharing is based on the type
of service performed and the
place of service where it is
rendered
Professional: 105% of
Payment for
Not Applicable
Not Applicable
Medicare Facility:
Non-Preferred Providers*
140% of Medicare
PPO Dental
In the U.S.
Non-Preferred
OUTSIDE THE
Preferred Benefits
PLAN FEATURES
Benefits
U.S.
(In-Network)
(Out-of-Network)
$25 per calendar
Individual Deductible
year
$75 per calendar
Family Deductible
year
No Charge
No Charge
No Charge
Type A Expense
(Diagnostic & Preventive)
20% after deductible 20% after deductible
Type B Expense
(Basic Restorative)
50% after deductible 50% after deductible
Type C Expense
(Major Restorative)
$2,000
$2,000
Calendar Year Maximum $2,000
50% after $50
50% after $50 lifetime
50% after $50 lifetime
Coverage for Adults and
lifetime deductible deductible
deductible
Dependents up to age 20
$2,000
$2,000
$2,000
Orthodontic Lifetime
Maximum
Please refer to the Dental Plan Caveats below for additional benefit coverages for Types A, B and C
Services and Programs
Informed Health Line (24-hour nurse line)
International Disease Management
International Maternity Management Program
Wellness Checkpoint
Weight Watchers® Program
On-Line Global Health and Travel Information through HTH Worldwide
(http//www.aetnainternational.com)
Medical Plan Caveats
304
This plan includes coverage for women's preventive health benefits to the extent required under U.S.
federal law effective beginning with plan years starting on or after August 1, 2012.
Payment limits apply per individual on a calendar year basis. Only those out-of-pocket expenses resulting
from the application of a payment percentage may be used to satisfy the payment limit. Precertification
penalties are excluded from the payment limit.
There is cross-application between calendar year deductible, out of pocket maximum and lifetime
maximum across overseas, in-network and out- of network level of benefits.
Coverage maximums up to a certain number of days/visits per calendar year are reached by combining
the Preferred and Non-Preferred benefits up to the limit for either one plan or the other, but not both.
(Example, if the Preferred benefit is for 120 days and the Non-Preferred benefit is for 120 days, the
maximum benefit is 120 days, not 240 days).
Maternity expenses are covered as any other medical expense. Coverage is provided for an employee and
spouse and all female family members Pregnancy benefits do not continue to be payable after coverage
ends except in the event of total disability.
For contracted hospitals, the non-contracted Radiologist, Anesthesiologist and Pathologist (RAPS) are
paid at the preferred level, and will be subject to reasonable and customary charges. Note that this
payment method may apply to other providers.
Copayments and coinsurance for chiropractic visits are capped at 25% of the amount due to the
chiropractor
Benefit maximums per Calendar year are calculated between 01/01/2014 and 12/31/2014.
Pre-Existing Conditions:
 Option: Option 5 - (No Restriction)
 On Effective Date: Pre-existing condition limitation is waived on the effective date.
 After Effective Date: Pre-existing condition limitation is waived after the effective date.
 Pre-Existing Conditions is waived for dependents under age 19.
* Payment for Non-Preferred Providers We cover the cost of care differently based on whether health
care providers, such as doctors and hospitals, are "in network" or "out of network." We want to help you
understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear
how much more you will need to pay for this out-of-network care.
As an example, you may choose a doctor in our network. You may choose to visit an out-of-network
doctor. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor's
bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an
out-of-network doctor or hospital.
When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the
305
"recognized" or "allowed" amount. When you choose out-of-network care, Aetna "recognizes" an amount
based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how
much Aetna "recognizes" depends on the plan you or your employer picks.
Your out-of-network doctor sets the rate to charge you. It may be higher --sometimes much higher --than
what your Aetna plan "recognizes" or "allows." Your doctor may bill you for the dollar amount that Aetna
doesn't recognize. You must also pay any copayments, coinsurance and deductibles under your plan. No
dollar amount above the recognized charge counts toward your deductible or maximum out-of-pocket. To
learn more about how we pay out-of-network benefits visit Aetna.com. Type "how Aetna pays" in the
search box.
You can avoid these extra costs by getting your care from Aetna's broad network of health care providers.
Go to www.aetna.com and click on "Find a Doctor" on the left side of the page. If you are already a
member, sign on to your Aetna Navigator member site.
This way of paying out-of-network doctors and hospitals applies when you choose to get care out of
network. When you have no choice (for example: emergency room visit after a car accident), we will pay
the bill as if you got care in network. You pay your plan's copayments, coinsurance and deductibles for
your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not
responsible for any outstanding balance billed by your providers for emergency services beyond your
copayments, coinsurance and deductibles
Dental Plan Caveats
PPO Dental
Type A
Includes Prophylaxis, Bitewing and full mouth series X-rays, Space Maintainers, Oral Exams, Fluoride
applications, Sealants, and Periapical X-rays.
Type B
Includes Fillings, Simple Extractions and Oral Surgery.
Type C
Includes Crown Lengthening, Crown Buildup, Inlays/onlays, Bridgework, Osseous surgery, Soft tissue
grafts, Partial and full bony impactions, General anesthesia and intravenous sedation, Dentures (benefit
includes all relines, rebases and adjustments within 6 months of installation), Molar root canal therapy,
Prosthetic repairs, and Occlusal Guards (for bruxism only).
Other Aetna Programs
When you enroll in the Aetna Medical, Dental and Vision Expat Benefits you and your covered
dependents have access to several resources administered by Aetna. These programs are designed
to provide you with personalized information, additional support and help coordinating your care.
Participation is voluntary and completely confidential.
How the Life and Accidental Death and Dismemberment (AD&D) Plan Works
306
The life and accident insurance plans offer you and your family the opportunity to have financial
protection when you may need it most. The life insurance plans are administered by Zurich.
Life Insurance provides your beneficiary with a benefit in the event of your death
AD&D Insurance provides an additional benefit if you die or suffer a serious injury as result of an
accident (e.g. lose a lib, become paralyzed, lose your hearing, speech or sight)
Company-Provided Life and AD&D Insurance
SPE provides the following Life and AD&D Insurance at no cost to you. Life and AD&D
Insurance coverage is equal to one times your base salary to a maximum of $1,000,000. Guarantee
Issue Amount is $500,000, any amounts in excess requires Evidence of Insurability.
Supplemental Life and AD&D Insurance
You can choose to purchase Supplemental Life and AD&D Insurance from 1, 2, 3 or 4 times your
annual base salary up to $1,000,000 (combined basic and supplemental coverage). All amounts
are rounded to the next higher multiple of $1,000, if not already an exact multiple thereof.
You must submit an Evidence of Insurability (EOI) form and receive insurance company approval
under the following circumstances:
 You enroll for coverage for the first time and your basic coverage exceeds the Guarantee
Issue Amount;
 You re-enroll for coverage after your coverage ends for any reason;
 You enroll for an increase in your coverage above the Guarantee Issue Amount.
Contact your employer if you have questions about EOI.
Accelerated Death Benefit Option
The Accelerated Death Benefit option allows you to receive a one-time partial life insurance
benefit if, while covered under the Plan, You are diagnosed with a Terminal Illness and not
expected to survive more than 12 months. The Accelerated Death Benefit is subject to the terms
and conditions of the Policy.
This benefit option does not apply to any Terminal Illness resulting from an intentionally selfinflicted injury or suicide attempt.
You may request and receive an Accelerated Death Benefit under this Plan only once on your own
behalf.
The amount of the Accelerated Death Benefit available is a percentage of the amount of employee
term life insurance that you elected under the Plan. You may request up to 50% of the term life
insurance that is currently in effect for you or the person for whom you are making the request on
the date we receive proof that you are terminally ill. But the amount you request may not be:
 Less than $5,000; or
 More than $150,000.
307
Accidental Death and Dismemberment (AD&D) Benefits
How the Plan Works
The Accidental Death and Dismemberment benefit covers losses you suffer solely and as a direct
result of an Accidental Bodily Injury that occurs while coverage is in effect. The Accidental Death
and Dismemberment benefits are payable in addition to any other coverage you may have from
Your Employer.
Covered Loss Schedule
Loss
Percentage of the AD&D Coverage
Amount Paid
Life
Sight in both eyes
One hand and sight in one eye
One foot and sight in one eye
Speech and hearing
Quadriplegia
Triplegia
Paraplegia
Sight of one eye
Speech or hearing
Hemiplegia
Thumb and index finger from one hand
Uniplegia
100%*
100%
100%
100%
100%
100%
100%
100%
75%
75%
50%
50%
50%
50%
25%
25%
When Coverage Ends









Your coverage under this Plan ends on the earliest of:
the date the Policy or a Plan is cancelled;
You voluntarily stop Your coverage;
the date You are no longer in an Eligible Class;
the date You are no longer eligible for coverage;
the date Your Eligible Class is no longer covered;
the last day of the period for which You made any required contributions;
the last day You are in Active Employment;
Your return to the U.S.A. or your country of residence for more than 180 days;
308





Your employment stops for any reason, including job elimination, or being placed on
severance. This will be either the date you stop Active Employment, or the day before the
first premium due date that occurs after you stop active employment;
the date on which You are age 70;
the date on which You retire;
the date of Your death; or
the date on which You begin active duty in the armed forces of any country.
Conversion Benefit
A Life Conversion option may be available without a medical exam if you apply for it within 31
days of your loss of coverage under this Plan.
Long-Term Disability (LTD) Plan
How the Plan Works
Long Term Disability Plan provides financial protection for you by paying a portion of your
income if you become disabled due to an Illness or Injury while covered under this Plan. The
amount you receive is based on the amount you earned before your disability began.
Cost of Coverage
SPE provides basic LTD coverage at no cost to you.
Premium Waiver
If you become disabled, no premium payments are required for your coverage while you are
receiving benefits under this Plan, provided the premium was paid during the Elimination Period.
Monthly Benefit
Monthly Benefit Percentage: 60% of covered monthly earnings to a maximum benefit of $12,500
per month.
Your benefit may be reduced by Deductible Sources of Income and Disability Earnings. Some
disabilities may not be covered or may have limited coverage under this Plan.
Minimum monthly benefit is $100 per month. Maximum benefit period is to age 65.
Definition a Long Term Disability
During the Elimination Period, you are disabled when Zurich determines that:
 you are unable to perform limited from performing the material and substantial duties of
your regular occupation due solely to your sickness or injury; and
 you are under the regular care of a physician; and
 you are not working at any job for compensation or profit;
After the Elimination Period, you are disabled when they determine that:
 you are unable to perform the material and substantial duties of your regular occupation
due solely to your sickness or injury; and
309


you are under the regular care of a physician; and
you have a 20% or more loss in your indexed monthly earnings due to that sickness or
injury.
After 24 months benefits have been payable, you are disabled when Zurich determines that due to
the same sickness or injury:
 you are unable to perform the duties of any gainful occupation for which you are
reasonably fitted by education, training or experience; and
 you are under the regular care of a physician;. and
 you have a 40% or more loss in your indexed monthly earnings due to the same sickness or
injury.
Zurich will assess your ability to work and the extent to which you are able to work by considering
the facts and opinions from your physicians and physicians and medical practitioners or vocational
experts of our choice.
Zurich may require you to be examined by a physician, other medical practitioner and/or
vocational expert of our choice. They will pay for this examination and can require an examination
as often as it is reasonable to do so. They may also require you to be interviewed by our authorized
representative. Refusal to be examined or interviewed may result in denial or termination of your
claim.
Eligibility for Benefits
You must be continuously disabled through your elimination period. The days that you are not
disabled will not count toward your elimination period. Zurich will treat your disability as
continuous if your disability stops for 15 days or less during the elimination period. No benefit is
payable for or during the elimination period.
Your Elimination Period is 180 days.
When Does Your Coverage End?
Your coverage under this Plan ends on the earliest of:
 the date the Policy , the Master Policy or a Plan is cancelled;
 the date on which your employer ceases to be a Participating Employer;;
 You voluntarily stop Your coverage;
 the date you are no longer in an Eligible Class;
 the date you are no longer eligible for coverage;
 the date your Eligible Class is no longer covered;
 the last day of the period for which you made any required contributions;
 the last day you are in Active Employment except as provided under the covered Layoff
 or Leave of Absence provision;
 You return to the U.S.A or your Country of Residence for more than 180 days;
310





Your employment stops for any reason, including job elimination, or being placed on
severance. This will be either the date you stop Active Employment, or the day before the
first premium due date that occurs after You stop Active Employment;
The date on which you are age 65;
the date on which you retire;
the date on which you voluntarily or involuntarily lose your professional license; or
the date on which you begin active duty in the armed forces of any country.
311
B.12 SEVERANCE PAY & BENEFITS
Employees classified by SPE as Regular, full-time, at-will, non-union employees with at least six
months of continuous service, who are not eligible for another severance pay plan, including
without limitation a Sony Pictures Imageworks severance pay plan, and who meet the eligibility
and other requirements of the SPE Severance Benefits Policy (“Severance
Policy”) are eligible to receive severance pay and benefits under the terms and conditions of the
Severance Policy in the event of a termination without cause, lay-off or job elimination.
In the event of a termination without cause, lay-off or job elimination, an eligible employee is
eligible to receive a severance payment in an amount equal to the number of months of the
employee’s base earnings as set forth in the schedule below:
Organization Level
1- 3
4
5
6
7-10
Number of Months of Base Earnings
1 month of base earnings
2 months of base earnings
An employee’s Organization Level is determined at the sole discretion of SPE.
Additionally, an eligible employee terminated due to a job elimination or a lay-off, whose
Organization Level is 1, 2 or 3, and who has completed more than five years of continuous service,
in addition to receiving one month of base earnings is also eligible to receive two weeks of base
earnings for each completed year of continuous service after the first five years up to a maximum
severance payment under the Severance Policy of 26 weeks times the employee’s base salary.
An eligible employee terminated due to a job elimination or a lay-off, whose Organization Level is
4, 5 or 6, and who has completed more than five years of continuous service, in addition to
receiving the above designated months of base earnings is also eligible to receive two weeks of
base earnings for each completed year of continuous service after the first five years up to a
maximum severance payment under the Severance Policy of 52 weeks times the employee’s
base salary.
For purposes of the Severance Policy, “continuous service” means the employee’s most recent
period of employment with the SPE. Adjusted service date is not used for purposes of calculating
continuous service under the Severance Policy. Completion of six or more months of service in
the employee’s last employment year will be considered a full year for this purpose.
In addition to the above severance payment, eligible employees who timely elect to continue their
(and, if applicable, their eligible family members’) coverage in SPE's medical (including
prescription drug), vision, and/or dental plans, as they may be modified from time to time, in
accordance with the Consolidated Omnibus Budget Reconciliation Act of 1986 ("COBRA"), will be
covered at SPE’s expense for an equivalent number of months as the employee’s severance
entitlement set forth above (the “COBRA Benefit”).* Eligible employees terminated due to a job
elimination or layoff, whose Organization Level is 1,2 or 3, are eligible for a COBRA Benefit of 3
312
months or an equivalent number of months as the employee’s severance entitlement set forth
above, whichever is greater. The COBRA Benefit applies only to the premiums associated with
the eligible employee’s (and, if applicable, his/her family members’) continued coverage and not
to any deductibles, co-payments, co-insurance or other out-of-pocket costs and commences on
the first day of the full month following the employee’s separation from service with SPE. The
COBRA Benefit will terminate automatically with respect to each covered individual upon the
earliest of (i) the expiration of the COBRA Benefit period (as described above), (ii) the date on
which the covered individual becomes covered under another group health plan, including a
spouse’s or domestic partner’s employer’s health plan (employees shall promptly notify SPE in
the event any covered individual obtains such coverage) or (iii) loss of eligibility for COBRA
coverage. Once the COBRA Benefit terminates, each covered individual may continue COBRA
coverage for the remainder of the COBRA continuation coverage period provided that he/she
remains eligible for such coverage and timely remits all required premiums associated with such
coverage.
* Note that the COBRA Benefit also applies to your eligible same-sex spouse or domestic partner
and his/her children who are not otherwise eligible for COBRA continuation coverage. Although
same-sex spouses/domestic partners and their children (who are not also your natural-born or
adopted children) are not generally eligible for COBRA continuation coverage, SPE offers
continuation coverage for such individuals on a voluntary basis.
Receipt of severance pay and the COBRA Benefit is expressly conditioned on the
employee timely signing an Acknowledgement and Release Form (“Release”) which
waives all legal claims that the employee may have against SPE and its parents,
subsidiaries, affiliates, successors, assigns, and employee benefits plans, and its and
their directors, officers, trustees, administrators, agents and employees, including but not
limited to claims arising from the employee’s employment or termination. The Release
must be signed by the employee within 45 days of the employee’s termination date and
returned to SPE for the employee to be eligible for severance pay and COBRA Benefit.
Severance payments are paid in a lump sum less applicable deductions and withholdings. The
complete terms and conditions of the Severance Policy are set forth in the Sony Pictures
Entertainment Severance Benefits Policy document. In the event of any inconsistency between
this summary and the Severance Policy document the terms of the Severance Policy document
shall govern.
SPE has the right to change or terminate the Severance Policy at any time. The Severance
Policy shall be effective as of April 1, 2011 and shall not apply to any termination, layoff or
job elimination prior to April 1, 2011.
313
APPENDIX C
FLEX-BENEFITS BY CHOICE PLAN
PLAN SUMMARY
I.
INTRODUCTION
Sony Pictures Entertainment Inc. (the “Company”) sponsors an employee benefits program known
as a flexible benefits plan, which is intended to be a cafeteria plan under § 125 of the Internal
Revenue Code of 1986, as amended. As a participant in the Sony Pictures Entertainment Inc.
Flex-Benefits By Choice Plan (the “Flex Plan”), you have the opportunity to choose benefits
provided through the Flex Plan (“Benefits”) and to pay your part of the cost for them using
“pre-tax dollars.” This means that you authorize your Participating Employer (see Appendix A) to
reduce your salary by the amount of your contribution for each Benefit you choose. This
arrangement is advantageous to you because you may save Social Security and income taxes on
the amounts you pay for your Benefits by salary reduction. The Flex Plan is part of the Sony
Pictures Entertainment Inc. Health and Welfare Benefits Plan (the “Master Plan”). All Benefits
provided under the Flex Plan (with the exception of Health Care FSA, Dependent Care FSA and
HSA Benefits) are provided pursuant to the terms of the Master Plan and related Benefit
Descriptions.
A.
Your Summary Plan Description
This summary of the Flex Plan (the “Summary”) describes the basic features of the Flex Plan and
explains the way the Flex Plan operates, and should be read in conjunction with the entire
Summary Plan Description for the Master Plan. It replaces and supersedes any and all booklets or
descriptions of the Flex Plan that you may have received in the past. This Summary is intended
only as a brief summary of the key provisions of the Flex Plan, not as a detailed comprehensive
description of all of the Flex Plan's provisions. Complete information is contained in the written
Flex Plan document which is maintained by SPE. In the event of an inadvertent discrepancy
between the information in this Summary and the actual provisions of the Flex Plan, the terms of
the written Flex Plan document will rule.
Throughout this Summary, the words “we,” “our,” “us,” and “the Company” mean Sony Pictures
Entertainment Inc., and to the extent applicable, Participating Employers. “You” and “your” mean
the employee who is eligible to participate in the Flex Plan.
B.
Eligibility
An employee is eligible to participate in the Flex Plan if eligible under the Master Plan, as
described in the main Summary Plan Description for the Master Plan, subject to the limitations
below.
314
If you are a new employee, you will be eligible to participate in the Flex Plan on the first day of the
month following your hire date, or on the date in which your Master Plan election goes into effect.
Please note that regardless of the date your election goes into effect, only compensation paid after
your enrollment will be considered for purposes of contributions.
If you are an existing employee and you make a mid-year election under the Master Plan, you will
be eligible for the Flex Plan on the later of (1) the date in which your Master Plan election goes into
effect, or (2) the date your election forms are received in good order.
II.
BENEFITS OFFERED THROUGH THE FLEX PLAN
The Flex Plan has three main components, “Premium Conversion,” “Flexible Spending
Accounts,” and “Health Savings Accounts”.
The Premium Conversion component of the Flex Plan allows you to elect qualified Benefits that
the Company may make available for which you are eligible and to pay your part of the cost on a
pre-tax basis such as:





Medical
Dental
Vision
Life (up to $50,000 of coverage)
The Flexible Spending Accounts component allows you to establish a Health Care Flexible
Spending Account and a Dependent Care Flexible Spending Account. A Flexible Spending
Account or “FSA” is an arrangement that allows you to make pre-tax contributions to an account
each pay period, and then to be reimbursed from that account for certain types of expenses
incurred during the year. A Health Care FSA is used to reimburse you for your family's eligible
medical care expenses. A Dependent Care FSA is used to reimburse you for eligible expenses you
incur for dependent care needed so that you can work (or seek work). Health Care and Dependent
Care FSAs are described in more detail later in this Summary.
If you are eligible to contribute to a Health Savings Account or “HSA” because you are enrolled
in our high deductible health plan, the HSA component allows you to make HSA contributions on
a pre-tax basis through payroll deduction. The Company may, in its discretion, make employer
contributions to an HSA on your behalf. A HSA permits you to be reimbursed for qualifying
medical expenses that are not payable under the high-deductible health plan as well as other
qualifying medical expenses. Note that if you wish to contribute to an HSA during a Plan Year,
then during your enrollment you must elect a “limited” Health Care FSA, which limits the
expenses that are reimbursable to dental and vision care until you have met the minimum annual
deductible under our high deductible health plan, at which time all other permissible medical
expenses may be reimbursed.
III.
BENEFIT ELECTIONS
315
A.
Electing Your Benefits for the Flex Plan Year
The Flex Plan operates during a plan year that begins on January 1 and ends on the following
December 31. All Flex Plan elections are made on a plan year basis. This means that once you
have made your elections, they pertain to the entire plan year. They cannot be changed or
cancelled during that time except in certain limited situations, which are described in this
Summary. It’s very important that you compare your elections against your pay check to confirm
amounts being withheld. If you notice any discrepancies, contact the Plan Administrator
immediately.
If you first become eligible to participate in the Flex Plan during a plan year in progress, you have
31 days after you first become eligible to participate to elect and enroll for Benefits. Your initial
elections will pertain to the remaining part of that plan year. Then, before each new plan year
begins, you will have an opportunity to change or cancel your elections during the Flex Plan's
annual election period. The annual election period is described below.
In making your elections, you may elect and enroll for some or all of the Benefits available under
the Premium Conversion component of the Flex Plan and elect and enroll in a Health Care FSA,
Dependent Care FSA and/or HSA. You may also elect not to participate in the Flex Plan or HSA
for the plan year.
To enroll for any Benefit, you must complete an election notice and submit it to the Plan
Administrator before the end of the annual election period. When you make your elections, you
also authorize the necessary salary reductions for paying your part of the cost of the Benefits you
elect. The Plan Administrator will establish the annual election period each year, and will notify
eligible employees of the dates of the annual election period in advance. The Plan Administrator
may specify certain Benefits as automatically elected by each eligible employee for a certain plan
year, though you may decline such Benefits in writing prior to the end of the applicable annual
election period. Any election or waiver you make will remain in effect for the full applicable plan
year unless you revoke or change it in accordance with the provisions of the Flex Plan.
Once you are a participant in the Flex Plan, if you become eligible for additional Benefits during a
plan year, you will be given an opportunity to elect and enroll for the Benefits for which you are
newly eligible. Also, if you have elected Benefits under the Premium Conversion portion of the
Flex Plan and the cost of the Benefits changes during the plan year, the amount of your salary
reduction contributions will be automatically adjusted.
A.
Annual Election Period
Before the beginning of each plan year, the Plan Administrator will hold an annual election period.
During this time, you may make new elections for the upcoming plan year. If you do not complete
and submit an election form during the annual election period, then unless as otherwise set forth in
the annual enrollment materials distributed by your employer you will be deemed to have:

made the same election for the upcoming plan year as you made for the previous plan year,
for all Benefits included in the Premium Conversion component of the Flex Plan;
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B.

elected not to participate in the Flexible Spending Accounts component or Health Savings
Account component of the plan for the upcoming plan year, regardless of your election for
the preceding plan year; and

authorized salary reduction contributions for the upcoming plan year equal to your share of
the cost of each Benefit deemed to have been elected.
Changing Your Elections During a Flex Plan Year
You may not change or revoke your Benefits elections during the plan year except in accordance
with the following rules:
Mid-Year Election Changes Due to HIPAA Special Enrollment Rights
If you become covered, or your Spouse or dependent becomes covered, under our group
health plan during a “Special Enrollment Period” required by the Health Insurance
Portability and Accountability Act (“HIPAA”), you may prospectively make a
corresponding change in your Flex Plan election so that you may pay your contributions
for the group health plan Benefits on a pre-tax basis.
Under HIPAA, Special Enrollment Periods are generally allowed due to certain losses of
other group health coverage and changes in family status. A Special Enrollment Period is
allowed due to a loss of other group health coverage if you:

declined coverage under our group health plan when you first became eligible for it;

stated in writing that you did so because you had other group (or COBRA) coverage
(but only if we required such a statement when you declined coverage); or

lose the other group coverage and request enrollment in our group health plan within 31
days.
A Special Enrollment Period is allowed due to a change in family status if you are eligible
for coverage under our group health plan and you gain a dependent through:

marriage;

birth;

adoption; or

placement for adoption.
This election change may be made retroactive to the date you gained the new dependent.
If you become entitled to or cease to be entitled to Medicaid, or if your Spouse or
dependent Child does so, or if you, your Spouse, or your dependent Child lose coverage
under a state child health plan or qualify for premium assistance under Medicaid or under a
state child health plan, you may within 60 days of such event change your election with
respect to health Benefits.
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Mid-Year Election Changes Due to Eligible Status Changes.
If you experience an Eligible Status Change, you may prospectively revoke or change your
previous Benefits elections in a manner that is consistent with the Eligible Status Change.
Eligible Status Changes are changes in a person's eligibility status due to at least one of the
following events:

a change in your legal marital status through marriage, the death of your Spouse,
divorce, legal separation, or annulment;

a change in the number of your dependents for federal income tax purposes through
birth, adoption, placement for adoption, or the death of a dependent;

the beginning or termination of your employment or your Spouse’s or dependent's
employment;

a reduction or increase in your working hours or those of your Spouse or dependent,
including work-hour changes resulting from a switch between part-time and full-time
employment, strike, lockout, or the beginning or end of an unpaid leave of absence;

your dependent satisfying or ceasing to satisfy the requirements for eligibility (for
example, by attaining the limiting age); or

a change in your workplace or residence or that of your Spouse or dependent.
An election change is “consistent with” an Eligible Status Change only if it is related to and
corresponds with the particular Eligible Status Change that has occurred. For example,
you may not cancel coverage for your Spouse who has become eligible for coverage under
another plan due to an Eligible Status Change unless he or she actually becomes covered
under the other plan. However, if you are permitted to add coverage under our group
health plan Benefit for a Spouse or dependent due to an Eligible Status Change, you may
also, at the same time, add group health plan Benefits for your other eligible family
members. If you experience an Eligible Status Change and wish to change your Health
Care Flexible Spending Account election, you may only reduce your election to the extent
you have not been reimbursed for medical expenses.
Mid-Year Election Changes Due to Entitlement to COBRA
You may change your election with respect to health Benefits if you become, or your
Spouse or dependent becomes, entitled to continued coverage under our group health plan
under:

the federal law known as COBRA; or

a state-mandated continuation of group health plan coverage.
Mid-Year Election Changes Due to a Qualified Medical Child Support Order
A Qualified Medical Child Support Order (“QMCSO”) is a court judgment, decree, or
order (including a court's approval of a domestic relations settlement agreement) that
requires health plan coverage of your Child. If you are required to provide health coverage
to your Child(ren) by a QMCSO issued due to a divorce, legal separation, annulment or
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change in legal custody, you may change your Benefits elections with respect to our group
health plan Benefits.
Mid-Year Election Changes Due to Changes in Medicare Entitlement
If you become entitled to or cease to be entitled to Medicare, or if your Spouse or
dependent Child does so, you may change your election with respect to health Benefits.
Mid-Year Election Changes Due to Eligible Changes in Coverage under the Flex Plan
If coverage under any Benefit provided through the Flex Plan is significantly curtailed or
terminated during the plan year and you are affected by the change, you may make an
election change to elect another option (other than Health Care Flexible Spending Account
Benefits) providing similar coverage. Coverage under group health plan Benefits is
“significantly curtailed” only if there is an overall reduction in coverage that affects all
covered participants. If Benefits are significantly curtailed and no alternative option is
available under the Flex Plan, revocation of the election is permitted if the significant
curtailment results in a loss of coverage.
If Benefits are added to or eliminated from the Flex Plan during the plan year and you are
affected, you may make an election change to elect the new Benefits or replace the
eliminated Benefits with another Benefit (other than Health Care Flexible Spending
Account Benefits) providing similar coverage, if one is available under the Flex Plan.
Mid-Year Election Changes Due to Eligible Changes in Coverage under a Family
Member's Plan
In certain situations, you may make a prospective election change due to and consistent
with a change in coverage under a flexible benefits plan sponsored by the employer of your
Spouse, former spouse, or dependent. You can do so when the change in coverage results
from either: (1) an election change permitted under that plan due to an Eligible Status
Change or an eligible change in coverage; or (2) an election change made during that plan's
annual election period, if its plan year does not coincide with the plan year of our Flex Plan.
This paragraph does not permit election changes to Health Care Flexible Spending
Accounts.
Mid-Year Election Changes Due to Changes in Coverage Costs
If the cost that is charged to all participants for a Benefit is significantly increased (as
determined by the Plan Administrator in its discretion) during the plan year and you are
affected, you may prospectively change your election to elect another Benefit option
providing similar coverage, if one is available under the Flex Plan. If no such alternative
option is available, revocation of the election is permitted. If the cost that is charged to all
participants for a Benefit is significantly decreased during the plan year and you are
affected, you may prospectively reduce your election to reflect the decrease. This
paragraph does not permit election changes to Health Care Flexible Spending Accounts.
Mid-Year Election Changes in Dependent Care Flexible Spending Account Benefits
Due to Changes in Dependent Care Providers or Hours of Care Provided
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You may change your Dependent Care FSA election due to a change in your dependent
care provider. You may also change your election if there is a reduction in the number of
hours of dependent care services provided.
Mid-Year Election Changes in Dependent Care Flexible Spending Account Benefits
Due to Changes in Dependent Care Expenses
You may change your Dependent Care FSA election due to a cost change imposed by your
dependent care provider, unless that provider is your relative.
Mid-Year HSA Election Changes
You may prospectively change your HSA election at any time during the Plan Year, and it
shall become effective no later than the first day of the next calendar month following the
date on which you filed your election. Contact your HSA trustee/custodian for details.
Effective Date of Mid-Year Changes. Generally, a mid-year election change due to any of the
above events must be made within 31 days (60 days with respect to certain HIPAA special
enrollment rights) after the occurrence of the event. While timely submitted and approved
mid-year election changes will, subject to any requirements reflected in an applicable Benefits
Description, normally be effective as of the date of the event giving rise to your right to make an
election change, pre-tax contributions will usually begin as soon as administratively practicable
following the date your election is received.
C.
Effect of Termination of Employment on Elections
If your employment terminates during a Plan Year, you will no longer be eligible to participate in
the Flex Plan. You will be deemed to have prospectively revoked your Benefit elections and to
have ended the receipt of Benefits for the remaining portion of the plan year.
Rehire rules. If your employment terminates but you are later rehired as an Eligible Employee by
a Participating Employer during the same plan year, you may resume participation in the Flex Plan
only in accordance with the following rules:

If you are rehired within 30 days following your termination of employment, your Benefit
elections that were in effect prior to the date of termination of employment will be
automatically reinstated for the remainder of the plan year.

If you are rehired more than 30 days after your termination of employment, you may make
new elections prospectively for the remainder of the plan year without regard to your prior
elections.
HSA Benefit elections will only be reinstated if you are HSA eligible. Moreover, special rules
apply with respect to reinstating Health Care FSA Benefits. Contact the Plan Administrator if you
have any questions regarding your Benefit elections upon termination and/or rehire.
COBRA & USERRA. If you are eligible for continuation of group health plan Benefits provided
through the Flex Plan due to COBRA or the Uniformed Services Employment Rights and
Reemployment Act of 1994 (“USERRA”), you may continue to participate in the Flex Plan with
respect to your continued group health plan Benefits following your termination of employment.
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Contributions for continued group health plan Benefits under COBRA and USERRA will be made
on an after-tax basis.
IV.
A.
CONTRIBUTIONS FOR BENEFITS
Contributions for Your Benefits
Your contributions toward the costs of Benefits are paid by salary reduction. Your compensation
will be reduced by the total amount of your contributions for the Benefits you elect. Your pay in
each pay period will be reduced by a proportionate amount of the total annual contribution. The
reduction in your pay will be adjusted automatically in the event of an insignificant change (as
determined by the Plan Administrator in its discretion), during the plan year, in your cost for the
Benefits you have elected.
Benefits provided to you will end if you fail to make the required contributions for the Benefits. If
Benefits end for this reason, you may not resume premium payments or make new Benefit
elections within the Flex Plan during the remaining portion of the plan year.
The Company may make periodic contributions toward the cost of some or all of the Benefits
provided under the Flex Plan. We reserve the right to increase, decrease, or eliminate our
contribution for any Benefit available under the plan at any time.
B.
Contributions During a Leave of Absence
In General
If you go on a qualifying leave of absence under the Family and Medical Leave Act (“FMLA”),
then to the extent required by the FMLA, the Company will continue to maintain your
participation in the plan’s group health plan Benefits (e.g., medical, dental, vision, Health Care
FSA) on the same terms and conditions as if you were an active employee.
Employees on a Paid Leave of Absence
If you have elected group health plan Benefits through the Flex Plan, you continue to be eligible to
participate in the plans while you are on a paid leave of absence (FMLA or non-FMLA). That
means you will continue to make payroll deductions to your account(s) and can continue to submit
claims for eligible expenses incurred by you and your eligible dependents.
Employees on an Unpaid Leave of Absence
In the event you are on an unpaid FMLA leave, you may elect to continue your health Benefits
during the leave. If you continue to elect to continue health coverage while on leave, then you may
pay your contributions in one of the following ways:

with after-tax dollars, sending monthly payments to the Company by the due date
established by the Plan Administrator;

with pre-tax dollars, by pre-paying your contributions for the expected duration of the
leave out of pre-leave compensation. To pre-pay contributions, you must make a special
election to that effect prior to receiving such compensation; or
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
with pre-tax dollars, by having “catch-up” amounts from your compensation deducted
upon your return.
If your coverage ceases while on FMLA leave (e.g., for nonpayment of required contributions),
then you may re-enter the plan upon return from such leave on the same basis as you were
participating prior to the leave, or at a coverage level that is reduced pro rata for the period of
FMLA leave during which you did not pay contributions.
If you take a non-FMLA leave or if you remain on leave after your FMLA is exhausted, your
Benefits may continue at the discretion of the Plan Administrator. Further, non-health Benefits
such as life insurance and Dependent Care FSA and domestic partner coverage may be continued
at the discretion of the Plan Administrator and as allowed under the Benefit Descriptions.
Please note that starting or returning from a leave of absence is considered a “qualified status
change” and you can change your contribution amount when you return from your leave to adjust
the amount being deducted from your pay provided you comply with plan rules.
V.
A.
FLEXIBLE SPENDING ACCOUNT BENEFITS
Flexible Spending Account Benefits
Flexible Spending Account (“FSA”) Benefits are made available to you through the Flex Plan. An
FSA is an arrangement whereby you may be reimbursed for certain types of eligible expenses
incurred during the plan year up to a specified amount you have elected. You make salary
reduction contributions during the plan year totaling your annual FSA Benefit amount. As eligible
expenses are incurred during the plan year, you may then be reimbursed by filing a valid request
for reimbursement.
FSA Benefits may consist of Dependent Care Flexible Spending Account Benefits and/or Health
Care Flexible Spending Account Benefits. The two types of FSA Benefits are separate and distinct
from one another. Your contributions for each FSA are allocated separately and cannot be
combined or intermingled. Reimbursements from each type of FSA are limited to those allowable
under the applicable section of the Internal Revenue Code.
Note that the expenses of a Domestic Partner and his or her children are only eligible for
reimbursement under an FSA if such individuals qualify as your tax dependent for federal income
tax purposes (discussed more below).
B.
How to Request Reimbursement
In order to receive reimbursement for eligible health care expenses or eligible dependent care
expenses, you will need to complete and submit a claim form that is available at www.aetna.com
or www.payflexdirect.com. You must include with the claim form a copy of the bill or
explanation of benefits that includes the date of service, the patient’s name, a description of the
service, the amount you paid and a receipt of payment. Claims should be submitted to the FSA
Claims Administrator as indicated in Section IX. General Plan Information.
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If you have any questions regarding claim reimbursement, please contact the FSA Claims
Administrator.
C.
Cut-off Date for Requesting Reimbursement
You have until March 31 of each year to file all requests for reimbursement of eligible expenses
incurred during the immediately prior plan year.
D.
Forfeiture of Unused Balances
In accordance with federal rules governing FSAs, you must forfeit any unused balance remaining
in an FSA after the cut-off date for requesting reimbursement for each year. This means that after
March 31 of each year, you will lose any amounts deposited in your FSA during the prior plan year
that remain unused in your FSA. Because of this “use-it-or-lose-it” rule, it is very important that
you estimate your eligible expenses carefully in deciding the FSA Benefit amount you will elect
for each plan year. The Company may use forfeitures from all FSAs to pay Flex Plan expenses,
and it may use forfeitures from Health Care Flexible Spending Accounts to reduce premiums for
those accounts in the following plan year or to provide premium refunds to participants who have
Health Care Flexible Spending Accounts.
E.
Written Notice and Review of Claim Denials
You are entitled to written notice and a full and fair review of denials (if any) of reimbursement
requests (claims) for Health Care and/or Dependent Care FSA Benefits. Please see the “Claims
Procedures” section, below, for an explanation of the Flex Plan’s claims procedures. Remember,
you must file all claims in accordance with the procedures established by the appropriate
Claims Administrator.
VI.
A.
HEALTH CARE FLEXIBLE SPENDING ACCOUNT BENEFITS
Benefit Limits
If you elect Health Care FSA Benefits, the annual benefit amount you may elect is subject to
certain minimum and maximum limits. The maximum amount you may elect is $2,550 (as
indexed) and the minimum amount, if any, will be communicated in the Flex Plan’s enrollment
materials.
B.
Eligible Health Care Expenses
Unless you have elected a limited Health Care FSA (described below), expenses are reimbursable
from your Health Care FSA if they:

are incurred by you, your Spouse, or your dependent;

are incurred during a plan year for which you elected Health Care FSA Benefits;

will not be reimbursed from any other source, including any health insurance plan;
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
are for services or supplies that fall within the definition of “medical care” in § 213 of the
Internal Revenue Code or reimburse the cost of over-the-counter medicines or drugs only if
they are purchased with a prescription or are for the cost of insulin as per § 9003 of the
PPACA; and

are not otherwise precluded from reimbursement by applicable sections of the Internal
Revenue Code, U.S. Treasury Department Regulations, rulings, or opinions, or other
applicable laws, regulations, rulings or opinions.
Generally, most expenses that can be itemized as medical care expenses for federal income tax
purposes are eligible for reimbursement from your FSA. However, if it is unclear whether a
particular type of expense is eligible, it is your responsibility to confirm that the expense is
reimbursable before submitting a request for reimbursement. This can be done by seeking advice
from your personal tax advisor or from the Internal Revenue Service (“IRS”).
For a list of expenses that typically qualify as eligible expenses for Health Care FSA purposes, go
to www.aetna.com or www.payflexdirect.com.
REMEMBER, if you wish to contribute to an HSA during a Plan Year then you must elect a
“limited” Health Care FSA. The “limited” Health Care FSA limits the expenses that are
reimbursable to dental and vision care until you have met the minimum annual deductible
under our high deductible health plan, at which time all other permissible medical expenses
may be reimbursed.
C.
Definition of Dependent for Health Care FSA Purposes
Generally for Health Care FSA purposes, your eligible dependents are individuals who qualify as
your tax dependents under § 152(a) of the Internal Revenue Code determined without regard to
subsections (b)(1), (b)(2) and (d)(1)(B) thereof, except that any child to whom § 152(e) of the
Internal Revenue Code applies is treated as a dependent of both parents, and a child (as defined in
§ 152(f)(1)) who has not attained age 27 as of the end of the employee’s taxable year.
D.
Required Documentation of Expenses
As previously indicated, certain types of documentation are required when you file a request for
reimbursement. Each request must be accompanied by a written statement from the provider of
the health care services or supplies stating that the expense has been incurred and indicating the
amount of the expense. In addition, you must provide a written statement that the expense has not
been reimbursed, and will not be reimbursed, from any other source including other health
insurance coverage. We may also ask for other types of supporting documentation in order to
verify that the expenses you submit for reimbursement are eligible under the IRS rules.
If you seek reimbursement using a flexible spending debit card, some expenses will be validated at
the time the expense is incurred. You may still have to submit supporting documents for other
expenses. For more information, go to www.aetna.com or www.payflexdirect.com.
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If you do not provide the proper documentation for your claims, you must repay the plan for any
such undocumented expenses. If you fail to reimburse the Flex Plan, we are required to withhold
such unsubstantiated expenditures from your payroll to the extent permitted by law. Further, to the
extent there is insufficient money to be withheld from your payroll or such monies are unavailable,
any outstanding amounts will be applied to your future claims to the Flex Plan and the Flex Plan
will be required to collect any remainder from you personally.
E.
Full Amount of Elected Benefits Available Throughout the Flex Plan Year
The total amount of Health Care FSA Benefits you elect for the plan year is uniformly available for
the reimbursement of eligible expenses at all times during the plan year. This is true regardless of
the amount you have contributed to date at any point during the plan year. The maximum amount
of reimbursement available at any time is equal to the amount of the your total annual election less
the amount of reimbursements already made for eligible expenses during the plan year, if any.
F.
Heath Care FSA & COBRA Continuation
A federal law known as COBRA requires certain employers, like the Company, to provide
continuation rights to persons who lose their regular group health plan coverage in certain
situations. Health Care FSA Benefits are considered “group health plan coverage” for COBRA
purposes.
You may be eligible for COBRA continuation of your Health Care FSA Benefits if you would
ordinarily lose them due to termination of employment or a reduction in your work hours. To be
eligible, your remaining available Health Care FSA Benefits for the plan year must exceed the cost
for you to continue the Benefits under COBRA for the remaining portion of the plan year in
progress.
Continuation Coverage and Cost. If you continue your Health Care FSA Benefits under
COBRA, you may be reimbursed for eligible expenses incurred during the plan year up to the full
amount of your annual election. However, you must pay the full cost for the Benefits, including
any part that may have been paid previously by us, and including an additional amount for
administrative expenses, on an after-tax basis. You must pay the full amount monthly.
COBRA Notification and Election. If you are entitled to continue your Health Care FSA
Benefits under COBRA, we will notify you of your rights and provide you with election materials.
In order to elect COBRA continuation coverage you must apply for the coverage by submitting the
appropriate election form within 60 days after you receive notice.
Payment of COBRA Contributions. You must pay the first monthly contribution within 45 days
after making your COBRA election. A grace period of at least 30 days will be allowed for the
payment of each subsequent contribution.
Length of Continuation Coverage. If continuation coverage is available to you under the rules
described above and you timely elect to continue your Health Care FSA Benefits under COBRA,
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you will be allowed to remain a Flex Plan participant with respect to Health Care FSA Benefits.
You may do so until the earliest of the following dates:

the date the plan year in progress ends;

the date on which we stop providing any group health plan Benefits (including FSA
Benefits) to employees;

the date you fail to make the required payment for Benefits within 30 days after the due
date for the payment;

the date on which you become covered under Medicare; or

the date on which you become covered under another group health plan that does not have
a pre-existing condition limitation applicable to you.
COBRA continuation coverage during any subsequent plan year will be made available only in the
very limited circumstances under which it is required by applicable laws or regulations.
VII. DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFITS
A.
The Dependent Care Assistance Plan
The Company has established a Dependent Care Assistance Plan in order to make Dependent Care
Flexible Spending Account Benefits available through the Flex Plan. If you have elected
Dependent Care FSA Benefits, you may be reimbursed for eligible dependent care expenses
incurred during the plan year up to a specified amount you have elected.
B.
Limitations on Benefits
By law, the maximum aggregate benefit available to you is limited to $5,000 per calendar year, or,
if you are married and you file a separate income tax return, to $2,500 per calendar year. The
aggregate maximum benefit, when taken with other such reimbursements, is further limited to the
lesser of your earned income (as defined in § 32 of the Internal Revenue Code) for the taxable year
or that of your Spouse. The annual benefit amount you may elect is also subject to certain
minimum and maximum limits established by the plan. We will inform you of the applicable
limits for each plan year before the annual election period.
C.
Eligible Dependent Care Expenses
Expenses that may be reimbursed through your Dependent Care FSA are limited to those which:

are incurred by you or your Spouse while you were a participant in the Flex Plan during a
plan year for which you elected Dependent Care FSA Benefits;

are incurred to enable you to maintain or seek gainful employment;
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
are incurred for the care of “qualifying individuals” (explained below) if paid for by you,
would be considered “employment-related expenses” as defined in § 21(b) of the Internal
Revenue Code (explained below);

are not for services provided by your dependent (as described in § 152 of the Internal
Revenue Code) or by your child under age 19;

will not be reimbursed from any other source; and

are not otherwise precluded from reimbursement by applicable sections of the Internal
Revenue Code, U.S. Treasury Department Regulations, rulings, or opinions, or other
applicable laws, regulations, rulings or opinions.
It is your responsibility to determine which expenses are eligible for reimbursement from your
Dependent Care FSA, although the Claims Administrator may deny any expenses submitted for
reimbursement which it determines are not Eligible Dependent Care Expenses. This can be done
by seeking advice from your personal tax advisor or from the Internal Revenue Service (“IRS”).
Additional information about eligible dependent care expenses is also available in IRS Publication
503.
Note that in some cases, the Dependent Care Tax Credit could be more advantageous than
participating in the Dependent Care FSA. You are encouraged to consult with a qualified tax
advisor before making any election under the plan.
D.
Qualifying Individuals
A “qualifying individual” is an individual for whom you have a relationship what meets the
requirements of § 21(b)(1) of the Internal Revenue Code. This is:
E.

a child under 13 years of age for whom you are entitled to a dependency deduction on your
federal income taxes. Note: A child of divorced parents is a qualifying individual only for
the custodial parent of whom he or she is a dependent.

any other qualifying dependent of yours who is physically or mentally incapable of caring
for him- or herself, regardless of age, has the same principal place of abode as you for more
than half of the year – and meets the other conditions imposed by the definition of
qualifying individual; and

your Spouse who is physically or mentally incapable of caring for him- or herself and who
has the same principal place of abode as you for more than half the year.
Employment-Related Expenses
In general, “employment-related expenses” are those that are for the care of a qualifying individual,
and that are incurred so that you can maintain (or seek) gainful employment. They must be
expenses that enable you to work, not just expenses that are incurred while you are at work.
Expenses for household services that are related to the care of a qualifying individual may also be
reimbursed. For example, expenses that are for the care of a qualifying individual and the service
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of cooking meals for that qualifying individual while he or she is in the care of the dependent care
provider are reimbursable. “Care” of a qualifying individual means providing for his or her
well-being and protection. Expenses for food, clothing, and education are not reimbursable unless
they are inseparable from and incidental to the expenses for the dependent care. For example, a
babysitter's expenses are covered even if the babysitter also provides lunch to the child as an
incidental part of his or her care. IRS Publication 503 provides more detailed information about
eligible dependent care services.
F.
Required Documentation of Eligible Dependent Care Expenses
Requests for reimbursement of dependent care expenses must include a written statement
containing information needed to verify the eligibility of the expenses and to operate the Flex Plan
in accordance with all legal requirements. Information that may be required includes but is not
limited to the following: the name of each dependent for whom services were provided; the
relationship of each dependent to you; the exact nature of the services performed; the amount of
the requested reimbursement; the relationship of the service provider to you, if any; if the services
were performed by your child, the age of the child providing the care; the place where the services
were performed; if services were performed outside your household, a statement as to whether the
dependent spends the required amount of time in your household; if services were performed in a
daycare center, information needed to verify that the facility qualifies as a “dependent care center”
as defined in the applicable regulations; if you are married, a statement of your Spouse's earned
income, or information needed to verify that an unemployed Spouse is either incapacitated or is a
full-time student for the required portion of the year; and a statement that the expenses have not
been reimbursed, and are not reimbursable, from any other source.
Note that eligible dependent care expenses are considered incurred when the care is provided,
regardless of when the provider of care bills, charges for, or is paid for the services.
You will also need to file IRS Form 2441 with your federal income tax return. Please retain
adequate records for the claims you were reimbursed as you will need them to complete IRS Form
2441.
VIII. HEALTH SAVINGS ACCOUNT
A.
General
The Health Savings Account (“HSA”) component of the Flex Plan permits eligible employees to
make pre-tax contributions to HSAs established and maintained outside the Flex Plan with an HSA
trustee/custodian. For purposes of the Flex Plan, HSA Benefits consist of the ability to make such
pre-tax contributions. The Company may, in its discretion, make employer contributions on
behalf of an HSA eligible employee to an HSA in accordance with reasonable procedures adopted
by the Plan Administrator. The amount of any such employer contributions will be communicated
to eligible employees during the enrollment period.
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An HSA is not an employer-sponsored employee benefit plan. It is an individual trust or custodial
account that you open with an HSA trustee/custodian to be used primarily for reimbursement of
“eligible medical expenses” as set forth in § 223 of the Internal Revenue Code. The HSA
trustee/custodian establishes and maintains the HSA. The HSA trustee/custodian will be chosen by
you, and not by the Company, though the Company may limit the number of HSA providers to
whom it will forward pre-tax and/or any employer contributions. The Company has no authority or
control over the funds deposited in any HSA.
The Plan Administrator will maintain records to keep track of pre-tax HSA contributions made
under the Flex Plan and any related employer contributions, but it will not create a separate fund or
otherwise segregate assets for this purpose. Neither an HSA nor the HSA component of this Flex
Plan is subject to ERISA.
B.
HSA Eligibility
To participate in the HSA component of this plan, you must be “HSA eligible”. This means that
you are eligible to contribute to an HSA under the requirements of § 223 of the Internal Revenue
Code and that you have elected to participate in the Company’s high deductible health plan and
have not elected any disqualifying non-high deductible health plan coverage. If you elect HSA
Benefits, you will be required to certify that you meet all of the requirements under § 223 of the
Internal Revenue Code. To find out more about HSA eligibility requirements and the
consequences of making contributions to an HSA when you are not eligible (including possible
excise taxes and other penalties), see www.aetna.com or www.payflexdirect.com or refer to IRS
Publication 969 (Health Savings Accounts and Other Tax-Favored Health Plans).
In order to elect HSA Benefits and receive any employer contributions, you must establish and
maintain an HSA outside of the Flex Plan with an HSA trustee/custodian and you must provide
sufficient identifying information about your HSA to facilitate the forwarding of your pre-tax
contributions and/or any employer contributions through the Company’s payroll system to your
HSA trustee/custodian.
C.
Limited Health Care FSA
As previously indicated, if you elect Health Care FSA Benefits, you cannot also elect HSA
Benefits (or otherwise make contributions to an HSA) unless you elect the “limited” Health Care
FSA coverage option. In the event that an expense is eligible for reimbursement under both the
“limited” Health Care FSA and the HSA, you may seek reimbursement from either the Health
Care FSA or the HSA, but not both.
D.
Maximum HSA Benefits
Your annual contribution for HSA Benefits is equal to the annual benefit amount that you elect.
The amount you elect must not exceed the statutory maximum amount for HSA contributions
applicable to the high deductible health plan coverage option (i.e., single or family) for the
calendar year in which the contribution is made – e.g., for 2015 these are $3,350 for single and
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$6,650 for family. An additional catch-up contribution of $1,000 may be made if you are age 55 or
older (you must certify your age to the Company).
In addition, the maximum annual contribution shall be:


E.
reduced by any employer contribution made on your behalf (other than pre-tax
contributions) under the Flex Plan; and
pro-rated for the number of months in which you are “HSA eligible” (as described above).
Tax Treatment of HSA Benefits
You may save both federal income taxes and FICA (Social Security) taxes by participating in the
Flex Plan. However, very different rules apply with respect to taxability of HSA Benefits than for
other Benefits offered under the plan. For more information regarding the tax ramifications of
participating in an HSA as well as the terms and conditions of your HSA see the communications
materials provided by your HSA trustee/custodian and see IRS Publication 969 (Health Savings
Accounts and Other Tax-Favored Health Plans). Note that the Company cannot guarantee any
specific tax consequences resulting from your participation in the Flex Plan. Ultimately, it is your
responsibility to determine the tax treatment of HSA Benefits. Remember that the Plan
Administrator is not providing legal advice. If you need an answer upon which you can rely, you
may wish to consult a tax advisor.
F.
Changing HSA Contribution Mid-Year
As previously indicated, you may increase, decrease, or revoke your HSA contribution election at
any time during the Plan Year for any reason by submitting an election change form to the HSA
trustee/custodian (or to its designee) in accordance with plan procedures, and it shall become
effective no later than the first day of the next calendar month following the date on which you
timely filed your election. Your ability to make pre-tax contributions under the Flex Plan to the
HSA ends on the date that you cease to meet the eligibility requirements.
G.
For More HSA Information …
For details regarding your rights and responsibilities with respect to your HSA (including
information regarding the terms of eligibility, what constitutes a qualifying high deductible health
plan, contributions to the HSA, and distributions from the HSA), please refer to your HSA trust or
custodial agreement and other documentation associated with your HSA and provided to you by
your HSA trustee/custodian. You may also want to review IRS Publication 969 (Health Savings
Accounts and Other Tax-Favored Health Plans).
IX.
CLAIMS PROCEDURES
If (i) a claim for reimbursement under the Health Care Flexible Spending Account or Dependent
Care Flexible Spending Account components of the Flex Plan is wholly or partially denied, or (ii)
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you are denied a Benefit under the Flex Plan (such as the ability to pay for premiums on a pre-tax
basis) due to an issue germane to your coverage under the Flex Plan (for example, a determination
regarding a mid-year election change, a “significant” change in premiums charged, or eligibility
and participation matters under the Flex Plan), then you must follow the claims procedures for
“Post-Service Claims” set forth in Appendix D to the Summary Plan Description for the Master
Plan unless the Claims Administrator indicates other claims procedures apply. As previously
indicated, the Premium Conversion and Dependent Care FSA components of the Flex Plan are not
subject to ERISA or to ERISA’s claims and appeals procedures. Questions concerning your
claims or the procedures to be used when filing a claim should be directed to the appropriate
Claims Administrator.
Claims relating in any way to the HSA established and maintained by you outside of the Plan with
your HSA trustee/custodian (for example, issues involving the investment or distribution of your
HSA funds) shall be administered by your HSA trustee/custodian in accordance with the HSA
trust or custodial document between you and such trustee/custodian.
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APPENDIX D
HEALTH AND WELFARE BENEFITS PLAN
CLAIM PROCEDURES
Overview
These procedures describe how the Plan will handle claims for benefits. Informal inquiries about
benefits or the circumstances under which benefits might be paid will not be considered claims for
benefits. Any person who wishes to pursue a claim (“you”) should carefully review these
procedures. Use of these procedures is mandatory and you may not pursue other remedies that
may be available to you without first exhausting your remedies under these procedures. The Plan
Administrator in its settlor capacity reserves the right to change these procedures at any time. Note
that for purposes of filing claims and appeals under the Flex Plan, the Secondary Appeals and
Voluntary Appeals procedures described below do not apply, and the Premium Conversion and
Dependent Care FSA components of the Flex Plan are not subject to ERISA or ERISA’s claims
and appeals procedures.
Need to File Claim
In some instances, it may not be necessary for you to file a claim for benefits. For example, when
you incur medical expenses (or, in appropriate cases, are seeking advance authorization to incur
medical expenses) that are or may be covered by the Plan, the doctor or other provider may submit
a claim for reimbursement on your behalf. If the doctor or other provider does not submit a claim
for reimbursement on your behalf, then you will need to file a claim. When you must file a claim,
you must do so using the forms and procedures required for the particular benefit for which you
desire to make a claim.
For details regarding when you are required to file a claim for benefits and the procedures to be
filed in claiming a particular form of benefit (e.g., health insurance, disability insurance, life
insurance, etc.), please review the Benefit Description for that benefit or contact a member of the
Employer’s Benefits Department or Claims Administrator. If you attempt to file a claim other than
on the official forms, it may not be considered to be validly filed, which might slow down or even
preclude payment. Claim forms are available on the Employer’s intranet or by contacting the
appropriate Claims Administrator directly. Remember, you must file all claims in accordance
with the procedures established by the appropriate Claims Administrator.
Any attempt to receive benefits will not be considered a claim under these procedures unless you
properly file your claim for benefits in accordance with the procedures described above. Unless
otherwise stated in an applicable Benefit Description, you must file your claim within 1 year of
the date that you incurred the expense for which are seeking reimbursement. An expense is
considered incurred on the date that the services are rendered and not on the date that you are billed
for the services. If you fail to file a timely claim for benefits, your right to those benefits shall
lapse.
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Definitions
The capitalized terms listed below shall have the following meaning in these procedures:
“Adverse Benefit Determination” means a denial, reduction, or termination of, or a failure to
provide or make payment (in whole or in part) for a benefit, including a failure to provide payment
the decision is based on a determination of a participant’s or beneficiary’s eligibility to participate
in a plan. For PPACA claims, an Adverse Benefit Determination also includes a rescission of
coverage.
“Authorized Representative” – means the person whom the Claimant authorizes, in writing, to act
on his or her behalf. In addition, if the Claimant is your dependent and you are acting (or your
Spouse is acting) on your dependent’s behalf, you (or your Spouse) will be recognized as his or her
authorized representative, as will a Claimant’s court designated representative, and, as to “urgent
care” (as defined below), a health care professional with knowledge of the Claimant’s condition.
“Claimant” -- means a person who files a claim, or on whose behalf a claim is filed. In appropriate
contexts in the claims/appeals processing discussion that follows, “Claimant” also refers to a
person who is then actively serving as the Claimant’s Authorized Representative.
“Claims Administrator” – means the entity that is responsible for determining whether a Claimant
is entitled to the benefit sought, as designated in the Summary Plan Description for that benefit.
“Disability Claim” – means a claim for benefits under the Employer’s long-term disability or
short-term disability plan.
“Other Claim” – means any claim that is not a Disability Claim, Pre-Service Claim or Post-Service
Claim. Other Claims include, for example, claims that do not relate to the underlying benefits
payable under the Plan, such as eligibility or premium payments. Claims for benefits under the
Employer’s life insurance and accidental death and dismemberment insurance policies are also
considered “Other Claims”.
“PPACA Claim” – means a claim for benefits or a claim due to a rescission of coverage under the
Employer’s group health plan that is subject to enhanced claims procedures under the Patient
Protection and Affordable Care Act, and underlying regulations and guidance. In general, a
PPACA claim will be processed in the same manner as a Pre- or Post-Service Claim except where
indicated below.
“Post-Service Claim”—means a claim for benefits under the Employer’s group health or dental
plan or a claim regarding a rescission of coverage that constitutes a PPACA claim, none of which
is not a “pre-service claim”
“Pre-Service Claim” – means a claim under the Employer’s group health or dental plan that
requires advance approval or certification for a service, supply or procedure.
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“Reviewable Adverse Benefit Determination” means •
an Adverse Benefit Determination that involves medical judgment, including, but
not limited to, those based on the plan's or insurer’s requirements for medical
necessity, appropriateness, health care setting, level of care, or effectiveness of a
covered benefit; or its determination that a treatment is experimental or
investigational, but excluding any Adverse Benefit Determination that is based on a
determination that a Participant or Beneficiary fails to meet the eligibility
requirements under the Employer’s group health plan; and
•
rescission of coverage (cancellation or discontinuance of coverage that has a
retroactive effect).
“Urgent care” -- means services received for a sudden illness, injury, or condition that requires
immediate medical care to avoid serious deterioration of the Claimant’s health or to avoid severe
pain that otherwise could not be managed adequately.
Impartial Review
Claims and appeals are adjudicated in a way that ensures the independence and impartiality of
those involved in decision making. This means that hiring, firing, promotion or similar decisions
involving individuals making claims decisions will not be based on the likelihood that the
individual will support the denial of benefits.
Claimants and Their Authorized Representatives
A Claimant may file and pursue a claim or an appeal directly, or his or her Authorized
Representative may do so. Unless a Claimant has notified the Claims Administrator in writing
otherwise, the Claims Administrator may share or send all information and notices relating to the
claim to the Claimant’s Authorized Representative.
Even though a Participant may use a representative in the claims procedure process, he or she may
not assign the right to receive benefits to anyone without the Company’s and the Claim
Administrator’s written consent. If a Participant assigns the right to receive benefits to some other
party, the Plan may, but need not, treat the purported assignee as the Participant’s Authorized
Representative or a Claimant for claims procedure purposes. The Plan may, but need not, pay
purportedly assigned benefits to the purported assignee, in which case the payment shall satisfy the
Plan’s benefit payment obligation.
Initial Claims and Time Limits
Pre-Service Claims
A Pre-Service Claim will be decided, and the Claimant will be notified of the decision, within 15
days (or 72 hours, in the case of an Urgent Care claim, and for PPACA claims the Plan shall defer
to the attending provider with respect to the decision as to whether a claim constitutes an Urgent
334
Care Claim) and) after the Claims Administrator receives the claim. If a Pre-Service Claim is
improperly submitted, but it identifies the Claimant, medical condition, and service or supply for
which approval is requested, and it is submitted to a Plan representative responsible for handling
benefit matters, the Claimant will be notified of the failure within 5 days thereafter (within 24
hours thereafter if the claim is an Urgent Care claim) and of the proper procedures to be followed.
The notice may be oral unless the Claimant requests written notification. If the Claimant does not
present sufficient information to decide an Urgent Care Pre-Service claim, the Claimant will be
notified of the information necessary to complete the claim as soon as possible, but within 24
hours after the Plan’s receipt of the claim. The Claimant will be given a reasonable additional
amount of time, at least 48 hours, to provide the information, and will be notified of the decision
within 48 hours after the end of that additional time period or after receipt of the information, if
earlier. If a Claimant’s Urgent care or other Pre-Service claim is pre-approved and the Participant
receives the requested treatment, any subsequent challenge of reimbursement amounts will be
treated as a Post-Service Claim.
Post-Service Claims
A Post-Service Claim will be decided, and the Claimant notified of the decision, within a
reasonable period of time and no later than 30 days after the Claims Administrator receives the
claim.
Disability Claims
A Disability Claim will be decided, and the Claimant notified of the decision, within a reasonable
period of time and no later than 45 days after the Claims Administrator receives the claim.
Other Claims
An Other Claim will be decided, and the Claimant notified of the decision, within a reasonable
period of time and no later than 90 days after the Claims Administrator receives the claim.
Claims Processing Extensions
The Plan may extend the 15 day, 30 day, 45-day and 90-day periods described above, due to
circumstances outside the Plan’s control, up to an additional 15 days for Pre-Service or
Post-Service Claims, two 30-day periods for Disability Claims, and 90 days for Other Claims. If it
so extends, the Claimant will be notified of the extension before the end of the initial 15-day,
30-day, 45-day or 90-day period of the reason for the extension, and when the claim is expected to
be decided. For example, for Pre-Service, Post-Service and Disability Claims, those periods may
be extended if the Claimant has not submitted sufficient information, in which case the Claimant
will be notified of the specific information necessary and given an additional period of at least 45
days after receiving the notice to furnish that information. The period in which the claim must be
decided is tolled until the end of the 45-day period or the date the Claimant responds to the request,
if earlier.
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If a Participant is receiving an ongoing course of treatment, he or she will be notified in advance if
the Plan intends to terminate or reduce benefits for the course of treatment (other than because of
Plan amendment or termination) so that the individual will have an opportunity to appeal the
decision before the termination or reduction takes effect. Any denial of a Claimant’s request to
extend an ongoing course of treatment shall be treated as a claim denial and administered in
accordance with these procedures based on the type of claim (e.g., Pre-Service or Post-Service);
provided that if the course of treatment involves Urgent Care and the Claimant requests an
extension of the course of treatment at least 24 hours before its expiration, the Claimant will be
notified of the decision within 24 hours after receipt of the request.
Notice of Claim Decision
If a claim is denied, the Claimant will be sent written notice of the decision including the
following:
1. The reasons for the decision.
2. Reference to the Plan provisions on which the decision is based.
3. For Pre-Service, Post-Service or Disability Claims, if the reason for the denial is an internal
rule, protocol, guideline, or other similar criterion, a copy of it or a statement that it will be
provided to the Claimant free of charge on request.
4. A description of any additional information needed to support the claim and an explanation
of why that information is necessary.
5. For Pre-Service, Post-Service, or Disability Claims, if the reason for the denial is medical
necessity, experimental treatment, or similar exclusion or limit, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of the Plan to the
Claimant’s medical circumstances, or a statement that such an explanation will be provided
to the Claimant free of charge on request.
6. A description of the Plan’s review (i.e., appeal) procedures and the time limits applicable to
such procedures (and, if it is an Urgent Care Claim, a description of the expedited review
procedures).
7. Information concerning the Claimant’s right to bring a civil action for benefits under
ERISA § 502(a) following denial of an appeal.
For PPACA Claims, the Claimant will also be sent the following additional information:
1. Information regarding the claim, including the date of the service, the health care provider,
and the claim amount (if applicable) and a statement describing the availability upon
request of the diagnosis code and its corresponding meaning and the treatment code and its
corresponding meaning;
336
2. The denial code and its corresponding meaning, as well as a description of the standard, if
any, that was used in denying the claim (including a discussion of the decision, if the notice
pertains to the final internal adverse benefit determination);
3. A description of any available internal appeals and external review processes, including
information regarding how to initiate an appeal; and
4. Information regarding the availability of, and contact information for, an applicable office
of health insurance consumer assistance or ombudsman.
5. If 10 percent or more of the population residing in the claimant's county are literate only in
the same non-English language, as determined by the Department of Labor, then the Plan
will provide the following for written notice of a denial:

oral language services

a notice in any applicable non-English language, upon request, and

a one-sentence statement in notices indicating how to access language services.
Within 3 days after the Plan gives the Claimant this information orally as to an Urgent Care Claim,
it will provide written notice.
A claim will be deemed to be “denied” and thus trigger these notification requirements if the claim
decision denies, reduces, terminates, or fails in whole or in part to provide or pay for a benefit,
including determinations made on the basis of eligibility, utilization review, and restrictions
involving medical necessity or experimental treatments, and will include any reduction or
termination of reimbursement for a course of treatment before the expiration of a previously
approved time period or before completion of a previously approved number of treatments. A
claim will be deemed to be at least partially denied whenever the Plan pays less than the total
amount of expenses submitted for reimbursement even if the reduction is required under the terms
of the Plan (for example, because of copay or deductible requirements).
Appealing an Adverse Benefit Determination
A Claimant may appeal a claim denial, but must do so within 180 days following receipt of the
denial for Pre-Service, Post-Service or Disability Claims (or, in the case of an appeal of a denial
relating to the reduction or termination of reimbursement for any ongoing course of treatment,
within a reasonable period, not to exceed 180 days, following receipt of the denial) and within 60
days following receipt of the denial for Other Claims. A Claimant’s appeal will be decided, and
the Claimant will be notified of the decision, within 72 hours (for Urgent Care claims), 30 days
(for other Pre Service claims), 45 days (for Disability Claims), or 60 days (for Post-Service Claims
and Other Claims) after the Plan receives the appeal. If a group health plan provides two levels of
appeal, then the time to respond for each level of appeal is 15 days for Pre-Service Claims and 30
days for Post-Service Claims. For Other Claims, the time for deciding the appeal may be extended
337
an additional 60 days, provided the Claimant is notified of the extension before the end of the
initial 60-day period, of the reason for the extension, and when the claim is expected to be decided.
A Claimant who appeals may submit written comments, documents, records, and other
information relating to the claim, whether or not submitted in connection with the initial claim.
The Plan will provide the Claimant, on request and free of charge, with copies of all non-privileged
documents, records, and other information the fiduciary resolving the claim determines to be
relevant to the claim, and the name of any medical professional whose input was sought in
deciding the claim. Further, the Plan will provide the claimant, free of charge, with any new or
additional evidence considered, relied upon, or generated by the Plan (or at the direction of the
Plan) in connection with the claim. Such evidence will be provided as soon as possible and in
advance of the date on which the notice of final internal adverse benefit determination is required
to be provided under 29 CFR 2560.503-1(i) to give the claimant a reasonable opportunity to
respond prior to that date.
For Pre-Service, Post-Service and Disability Claims, the decision on review will be conducted by
Claims Administrator personnel who did not decide the initial claim and who are not their
subordinates. The reviewers will not afford deference to the initial adverse benefit determination.
They will take into account all information presented by the Claimant in support of the appeal,
including information not presented in connection with the initial claim. They will base their
decision on input from a health care professional who has appropriate training and experience in
the field of medicine involved in the medical judgment if the review would be decided in whole or
in part on a medical judgment, including determinations as to whether a particular treatment, drug,
or other item is experimental, investigational, or not medically necessary or appropriate. The
health care professional they consult with not be the same one utilized at the initial claim denial
stage or his or her subordinate.
An Urgent Care Claim denial may be appealed in an expedited manner by calling the member
services phone number on the health plan identification card.
Notice of Appeal Decision
If an appeal is denied, the Claimant will be sent written notice of the denial, including the
following:
1. The reasons for the decision.
2. Reference to the Plan provisions on which the decision is based.
3. For Pre-Service, Post-Service or Disability Claims, if the reason for the denial is an internal
rule, protocol, guideline, or other similar criterion, a copy of it or a statement that it will be
provided to the Claimant free of charge on request.
4. For Pre-Service, Post-Service or Disability Claims, if the reason for the denial is based on a
medical necessity, experimental treatment, or similar exclusion or limit, either an
explanation of the scientific or clinical judgment for the determination, applying the terms
338
of the Plan to the Claimant’s medical circumstances, or a statement that such an
explanation will be provided to the Claimant free of charge on request.
5. A statement that the Claimant is entitled to receive, on request and free of charge,
reasonable access to, and copies of, all documents, records, and other information relevant
to the claim for benefits.
For PPACA Claims, the Claimant will also be sent the following additional information:
1. Information regarding the claim, including the date of the service, the health care provider,
and the claim amount (if applicable) and a statement describing the availability upon
request of the diagnosis code and its corresponding meaning and the treatment code and its
corresponding meaning;
2. The denial code and its corresponding meaning, as well as a description of the standard, if
any, that was used in denying the claim (including a discussion of the decision, if the notice
pertains to the final internal adverse benefit determination);
3. A description of any available internal appeals and external review processes, including
information regarding how to initiate an appeal; and
4. Information regarding the availability of, and contact information for, an applicable office
of health insurance consumer assistance or ombudsman.
5. If 10 percent or more of the population residing in the claimant's county are literate only in
the same non-English language, as determined by the Department of Labor, then the Plan
will provide the following for written notice of a denial:

oral language services

a notice in any applicable non-English language, upon request, and

a one-sentence statement in notices indicating how to access language services.
6. Further, before any appeal denial based on information not considered or relied upon, the
claimant will be provided with:

new or additional evidence considered, relied upon, or generated by the Plan in
connection with the claim;

any new or additional rationale for a denial at the internal appeals stage, and

a reasonable opportunity to respond to such new evidence or rationale.
Second Appeal
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If you want the denial of your appeal reviewed, you must file for a second level of appeal within
180 days after you receive denial of your first appeal. Failure to file an appeal within the time
frame will result in a waiver of your rights to have your appeal reconsidered. This applies to all
types of appeals under the plans. The process and timing of this Second Appeal is the same as the
First Appeal. See above for more information.
You will also be informed of your right to seek a third voluntary level of appeal with the Plan
Administrator.
PPACA Claims
If a PPACA claim involves a Reviewable Adverse Benefit Determination the Claimant may
request to have the claim reviewed by an Independent Review Organization rather than request a
third voluntary appeal as provided below. The Claimant has up to four months after the date of
receipt of a notice of such Reviewable Adverse Benefit Determination to request an external
review of the PPACA Claim. Within five business days of receipt of the external review request,
the Plan will complete a preliminary review of the request to determine whether it is eligible for an
external review and within one business day after completing the preliminary review, the Plan will
issue a written notification to the Claimant either approving or denying the review. Any denial
will include the reasons why the request is ineligible and contact information for the Employee
Benefits Security Administration. If the request is incomplete, the notice will describe the
information needed to make the request complete and the Claimant will be able to complete the
request within the remainder of the four-month filing period or within 48 hours of receipt of the
notice, whichever is later. If the Claimant’s external appeal is approved, the claim will be assigned
to an accredited Independent Review Organization (“IRO”). The IRO is not bound by any
decisions or conclusions reached during the Plan’s internal claims and appeals process. Any
decision will be binding on both parties so the Claimant may not seek a third voluntary internal
appeal if his or her claim is denied by the IRO.
Third Appeal – Voluntary
A Claimant may request a third appeal if his or her medical Pre-Service or Post-Service (not
Urgent Care) Claim is denied after an internal appeal. Before filing this appeal, you must have
exhausted all other internal claims and appeals rights with the Claims Administrator.
This level of appeal is entirely voluntary. You are not required to pursue your appeal for a plan
benefit using this voluntary procedure. Instead, you are entitled, after your second appeal, to
pursue your rights in court. Please be aware that:

The plans will not assert a failure to exhaust administrative remedies if you decide to pursue
resolution of your appeal in court rather than through this voluntary appeal procedure.

The plans will agree that any statute of limitations applicable to pursuing your appeal in court
will be suspended while your appeal is being processed through this voluntary appeal
procedure.
340

No fees or costs are imposed on you as a part of this second level appeal process except for any
costs that are permitted under ERISA (e.g., reasonable charges for copies of plan documents).
In addition, you are responsible for any costs you incur on your own, including without
limitation, postage costs, attorney’s fees, and copy costs.
To file a voluntary third appeal, the Claimant (or Authorized Representative) must submit the
information listed below within 60 days of the date in which the Claims Administrator issued its
prior denial. Claims must be filed in writing with the Claims Administrator:
c/o SPE Benefits Committee
10202 West Washington Boulevard, SPP #3900
Telephone: (310) 244-4748
Fax: (310) 244-2226
The Claimant should include all documentation provided during the prior claim submission (initial
claim and appeals) as well as any written comments, documents, records, and other information
relating to the claim, even if not submitted in connection with the initial claim. The Plan will
provide the Claimant, on request and free of charge, with copies of all non-privileged documents,
records, and other information the fiduciary resolving the claim determines to be relevant to the
claim, and the name of any medical professional whose input was sought in deciding the claim.
Further, the Plan will provide the claimant, free of charge, with any new or additional evidence
considered, relied upon, or generated by the Plan (or at the direction of the Plan) in connection
with the claim. Such evidence will be provided as soon as possible and in advance of the date on
which the notice of final internal adverse benefit determination is required to be provided under 29
CFR 2560.503-1(i) to give the claimant a reasonable opportunity to respond prior to that date.
Upon receipt of your voluntary appeal for the plan benefit, the Claims Administrator (or its
delegate) will review your written appeal with a reasonable period of time, but not later than 90
days after its receipt of the appeal. The Claims Administrator may extend its review period of your
voluntary appeal for up to an additional 90 days if special circumstances require an extension of
time. If an extension is required, the Claims Administrator will notify you in writing before
expiration of the initial 90 day period of the reason for the extension and the date by which the
Claims Administrator expects to render its decision.
During its review, the Claims Administrator will:

Take into account all comments, documents, records, and other information submitted by you
or your Authorized Representative relating to your claim or appeal without regard to whether
such information was previously submitted or considered by the claims administrator.

Review your appeal in a manner that does not afford deference to the initial decision to deny
your claim or the previous decisions to deny your appeal.
341

Consult with a health care professional who has appropriate training and experience in the field
of medicine involved in the medical judgment, if the initial decision to deny your claim or
appeal was based in whole or in part on a medical judgment, including determinations with
regard to whether a particular treatment, drug or other item is experimental, investigational, or
not medically necessary or appropriate.
The Claims Administrator (or its delegate) has full discretion to grant or deny, in whole or in part,
any appeal made under this voluntary appeal procedure. The Claimant will be notified in writing
of the determination of the Claims Administrator (or its delegate) regarding the voluntary appeal.
If the Claims Administrator (or its delegate) decides to deny the voluntary appeal, the Claimant
will receive a written notice explaining in detail why the voluntary appeal has been denied and will
include all of the information indicated above.
If the claim is a PPACA claim and involves a Reviewable Adverse Benefit Determination the
Claimant may request to have the claim reviewed by an Independent Review Organization. The
Claimant has up to four months after the date of receipt of a notice of such Reviewable Adverse
Benefit Determination to request an external review of the PPACA Claim. Within five business
days of receipt of the external review request, the Plan will complete a preliminary review of the
request to determine whether it is eligible for an external review and within one business day after
completing the preliminary review, the Plan will issue a written notification to the Claimant either
approving or denying the review. Any denial will include the reasons why the request is ineligible
and contact information for the Employee Benefits Security Administration. If the request is
incomplete, the notice will describe the information needed to make the request complete and the
Claimant will be able to complete the request within the remainder of the four-month filing period
or within 48 hours of receipt of the notice, whichever is later. If the Claimant’s external appeal is
approved, the claim will be assigned to an accredited Independent Review Organization (“IRO”).
The IRO is not bound by any decisions or conclusions reached during the Plan’s internal claims
and appeals process. Any decision will be binding on both parties.
Other Claims Procedure Rules
A claim shall be deemed received by the Plan when it is received by the Claims Administrator, as
it reasonably determines.
A Claimant may agree to give the Plan more time to decide a claim, in which case the time limits
described above would be extended as agreed.
Notwithstanding anything to the contrary and to the extent applicable, claims and appeals shall be
handled in accordance with the U.S. Department of Labor’s claims procedure regulations,
currently set forth in 29 C.F.R. § 2560.503-1 et seq., which are incorporated by reference and DOL
Reg. 2590.715-2719 for PPACA Claims.
Litigating Claims
342
No Claimant shall file suit unless and until the Claimant exhausts his or her remedies under the
Plan’s claim procedures, and any such suit must be filed within one (1) year after the Claimant
exhausts those remedies.
Notwithstanding anything to the contrary in any pre-dispute arbitration agreement or provision, a
Claimant shall not be required to arbitrate any denied claim or appeal seeking Plan benefits
relating to any Pre-Service, Post-Service or Disability Claim.
343
APPENDIX E
Important Notice from Sony Pictures Entertainment Inc. About
Your Prescription Drug Coverage and Medicare
Medicare Part D Prescription Drug Coverage
IMPORTANT NOTICE FOR MEDICARE–ELIGIBLE EMPLOYEES AND COVERED
DEPENDENTS
Sony Pictures Entertainment (SPE) is required to provide the notice that follows to all Medicare
eligible plan participants. The purpose of the notice is to provide you with a statement of assurance
that while you are enrolled in Aetna Select EPO, Aetna PPO, Aetna Consumer Choice or Kaiser
HMO, the prescription drug coverage you have under any of these SPE medical plans is
“Creditable Coverage.”
This means that, on average, your SPE coverage is at least as good as the standard Medicare
prescription drug coverage. (For more information on Creditable Coverage, you can refer to the
“Creditable Coverage” section of the notice below.) Medicare prescription drug coverage is
optional, and you may find that you have all the coverage you need with SPE. If you decide in a
subsequent year that you want to enroll in a Medicare prescription drug plan, this notice will serve
as confirmation to Medicare that you had Creditable Coverage in the interim. As a result, you will
not have to pay a late penalty on your Medicare prescription drug plan monthly premium if you
decide to enroll during a subsequent annual enrollment window. Note, however, that if you opt out
(choose the “No coverage” option) with SPE, you do not have Creditable Coverage and may be
subject to a future premium penalty if you subsequently enroll in a Medicare prescription drug
plan. The notice that follows explains the effect of having Creditable and non-Creditable
Coverage.
IMPORTANT NOTIC E FROM SPE ABOUT YOUR PRESCRIPTION DRUG COVERAGE
AND MEDICARE
Please read this notice carefully and keep it where you can find it. This notice has information
about your current prescription drug coverage with SPE and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not you want to join
a Medicare prescription drug plan. If you are considering joining, you should compare your
current coverage, including which drugs are covered at what cost, with the coverage and costs of
the plans offering Medicare prescription drug coverage in your area. Information about where you
can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important facts you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You
can get this coverage if you join a Medicare prescription drug plan or join a Medicare Advantage
plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans
provide at least a standard level of coverage set by Medicare. Some plans may also offer more
coverage for a higher monthly premium.
80
344
2. SPE determined that the prescription drug coverage offered by SPE is, on average for all plan
participants, expected to pay out as much as standard Medicare prescription drug coverage pays
and is considered Creditable Coverage.
Because your existing coverage is, on average, at least as good as standard Medicare prescription
drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later
decide to join a Medicare prescription drug plan.
When Can You Join a Medicare Drug Plan?
You can join a Medicare prescription drug plan when you first become eligible for Medicare and
each year from October 15 through December 7. However, if you lose creditable prescription drug
coverage through no fault of your own, you will be eligible for a two month Special Enrollment
Period (SEP) to join a Medicare drug plan.
What Happens to Your Current Coverage If You Decide To Join a Medicare Drug Plan?
If you decide to join a Medicare prescription drug plan, your current SPE coverage is not affected.
If you decide to join a Medicare prescription drug plan and drop your SPE prescription drug and
medical coverage, be aware that you and your dependents may not be able to get this coverage
back. Please remember that your SPE prescription drug coverage is bundled with your medical
plan option. Therefore, there is no separate employee contribution for prescription drug coverage.
If you want to keep your SPE coverage and you want to avoid duplicate premiums, you should
NOT enroll in Medicare prescription drug coverage for 2014. Please contact us for more
information about what happens to your coverage if you enroll in a Medicare prescription drug
plan.
When Will You Pay a Higher Premium (Penalty) To Join a Medicare Drug Plan?
You should know that if you drop or lose your coverage with SPE and don’t join a Medicare
prescription drug plan within 63 continuous days after your current coverage ends, you may pay a
higher premium (a penalty) to join a Medicare prescription drug plan later. If you go 63 continuous
days or longer without creditable prescription drug coverage, your monthly premium may go up by
at least 1% of the Medicare base beneficiary premium per month for every month that you did not
have that coverage. For example, if you go 19 months without Creditable Coverage, your premium
may consistently be at least 19% higher than the base beneficiary premium. You may have to pay
this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In
addition, you may have to wait until the following October to join.
For More Information About This Notice or Your Current Prescription Drug Coverage:
If you have questions, call an SPE Benefits Connection representative toll-free at 1-866-941-4SPE
(4773).
NOTE: You’ll get this notice each year. You will also get it before the next period you can join a
Medicare prescription drug plan, and if this coverage through SPE changes. You also may request
a copy of this notice at any time from an SPE Benefits Connection representative toll-free at
1-866-941-4SPE (4773).
345
More detailed information about Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from
Medicare. You may also be contacted directly by Medicare prescription drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy
of the ―Medicare & You‖ handbook for the telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048
If you have limited income and resources, extra help paying for Medicare prescription drug
coverage is available. For information about this extra help, visit Social Security on the Web at
www.socialsecurity.gov, or call 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
prescription drug plans, you may be required to provide a copy of this notice when you join to
show whether or not you have maintained Creditable Coverage and whether or not you are
required to pay a higher premium (a penalty).
Date: October 31, 2015
Name of Sender: Sony Pictures Entertainment
Contact – Office: People & Organization – Total Rewards
Address: 10202 West Washington Boulevard,
SPP 3900, Culver City, CA 90232
Phone Number: 1-310-244-4000
346
APPENDIX F
Premium Assistance Under Medicaid and
the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage
from your employer, your state may have a premium assistance program that can help pay for
coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t
eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but
you may be able to buy individual insurance coverage through the Health Insurance Marketplace.
For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed
below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or
any of your dependents might be eligible for either of these programs, contact your State Medicaid
or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply.
If you qualify, ask your state if it has a program that might help you pay the premiums for an
employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as
eligible under your employer plan, your employer must allow you to enroll in your employer plan
if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must
request coverage within 60 days of being determined eligible for premium assistance. If you
have questions about enrolling in your employer plan, contact the Department of Labor at
www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your
employer health plan premiums. The following list of states is current as of July 31, 2015.
Contact your State for more information on eligibility –
ALABAMA – Medicaid
Website: http://www.medicaid.alabama.gov
Phone: 1-855-692-5447
ALASKA – Medicaid
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/
Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP
Website: http://www.azahcccs.gov/applicants
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
347
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/ - Click on
Programs, then Medicaid, then Health Insurance
Premium Payment (HIPP)
Phone: 404-656-4507
IDAHO – Medicaid
MONTANA – Medicaid
Medicaid Website:
http://healthandwelfare.idaho.gov/Medical/Medicaid/
PremiumAssistance/tabid/1510/Default.aspx
Website:
http://medicaidprovider.hhs.mt.gov/clientpages/
clientindex.shtml
Medicaid Phone: 1-800-926-2588
Phone: 1-800-694-3084
INDIANA – Medicaid
NEBRASKA – Medicaid
Website: http://www.in.gov/fssa
Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949
Phone: 1-855-632-7633
IOWA – Medicaid
NEVADA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
NEW HAMPSHIRE – Medicaid
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA – Medicaid
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
NEW JERSEY – Medicaid and CHIP
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website:
http://www.njfamilycare.org/index.html
MAINE – Medicaid
CHIP Phone: 1-800-701-0710
Website:
http://www.maine.gov/dhhs/ofi/public-assistance/inde
x.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP
NEW YORK – Medicaid
348
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
Phone: 1-800-657-3629
MISSOURI – Medicaid
NORTH DAKOTA – Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.h
tm
Website:
http://www.nd.gov/dhs/services/medicalserv/medica
id/
Phone: 573-751-2005
Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP
UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Website: http://health.utah.gov/upp
Phone: 1-888-365-3742
Phone: 1-866-435-7414
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
VIRGINIA – Medicaid and CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistanc
e.cfm
CHIP Website:
http://www.coverva.org/programs_premium_assistanc
e.cfm
CHIP Phone: 1-855-242-8282
RHODE ISLAND – Medicaid
Website: www.eohhs.ri.gov
Phone: 401-462-5300
WASHINGTON – Medicaid
Website:
http://www.hca.wa.gov/medicaid/premiumpymt/pages
/index.aspx
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
WEST VIRGINIA – Medicaid
Website:
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion
/Pages/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
WISCONSIN – Medicaid
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website:
http://www.badgercareplus.org/pubs/p-10095.htm
349
Phone: 1-800-362-3002
TEXAS – Medicaid
WYOMING – Medicaid
Website: https://www.gethipptexas.com/
Website: https://wyequalitycare.acs-inc.com/
Phone: 1-800-440-0493
Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2015, or for
more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
350

SONY PICTURES ENTERTAINMENT INC. HEALTH AND WELFARE

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