13-Attachment O - 2025 RETIREES MEDICAL PLAN 2 BOOKLET.PDF

Open Access Aetna Select medical plan

Booklet Prepared for:

Employer: City of Amarillo Contract number: MSA-0737475 Plan name: Open Access Aetna Select Option II - Retirees without

Medicare Plan Booklet: 4 Plan effective date: January 1, 2025 Plan issue date: November 15, 2024

Third Party Administrative Services provided by Aetna Life Insurance Company

Table of contents

Welcome

Coverage and exclusions

General plan exclusions

How your plan works

Complaints, claim decisions and appeals procedures

Eligibility, starting and stopping coverage

General provisions – other things you should know

Glossary

Schedule of benefits Issued with your booklet

Welcome

At Aetna®, your health goals lead the way, so we’re joining you to put them first. We believe that whatever you decide to do for your health, you can do it with the right support. And no matter where you are on this personal journey, it’s our job to enable you to feel the joy of achieving your best health.

Welcome to Aetna.

Introduction This is your booklet. It describes your covered services – what they are and how to get them. It also describes how we manage the plan, according to our policies, and applicable laws and regulations. The schedule of benefits tells you how we share expenses for covered services and explains any limits. Together, these documents describe the benefits covered by your Employer’s self-funded health benefit. Each may have amendments attached to them. These change or add to the document. This booklet takes the place of any others sent to you before.

It’s really important that you read the entire booklet and your schedule of benefits.

If your coverage under any part of this plan replaces coverage under another plan, your coverage for benefits provided under the other coverage may reduce benefits paid by this plan. See the Coordination of benefits - Effect of prior plan coverage section.

If you need help or more information, see the Contact us section below.

How we use words When we use:

“You” and “your”, we mean you and any covered dependents (if your plan allows dependent coverage) “Us,” “we,” and “our”, we mean Aetna Life Insurance Company (Aetna) Words that are in bold, these are defined in the Glossary section

Contact us Your plan includes the Aetna concierge program. It provides immediate access to consultants trained in the specific details of your plan.

For questions about your plan, you can contact us by:

Calling the toll-free number on your ID card Writing us at 151 Farmington Ave, Hartford, CT, 06156 Visiting https://www.aetna.com to access your member website

Your member website is available 24/7. With your member website, you can:

See your coverage, benefits and costs Print an ID card and various forms Find a provider, research providers, care and treatment options View and manage claims Find information on health and wellness

Your ID card Show your ID card each time you get covered services from a provider. Only members on your plan can use your ID card. We will mail you your ID card. If you haven’t received it before you need covered services, or if you lose it, you can print a temporary one using your member website.

https://www.aetna.com/

Wellness and other rewards You may be eligible to earn rewards for completing certain activities that improve your health, coverage, and experience with us. We may encourage you to access certain health services or categories of healthcare providers, participate in programs, including but not limited to financial wellness programs; utilize tools, improve your health metrics or continue participation as an Aetna member through incentives. Talk with your provider about these and see if they are right for you. We may provide incentives based on your participation and outcomes such as:

Modifications to copayment, deductible or payment percentage amounts Contributions to a health savings account Merchandise Coupons Gift cards or debit cards Any combination of the above

Discount arrangements We can offer you discounts on health care related goods or services. Sometimes, other companies provide these discounted goods and services. These companies are called “third-party service providers”. These third-party service providers may pay us so that they can offer you their services.

Third-party service providers are independent contractors. The third-party service provider is responsible for the goods or services they deliver. We are not responsible; but we have the right to change or end the arrangements at any time.

These discount arrangements are not insurance. We don’t pay the third-party service providers for the services they offer. You are responsible for paying for the discounted goods or services.

Coverage and exclusions

Providing covered services Your plan provides covered services. These are:

Described in this section Not listed as an exclusion in this section or the General plan exclusions section Not beyond any limits in the schedule of benefits Medically necessary. See the How your plan works – Medical necessity and precertification requirements section and the Glossary for more information.

Services that are not prohibited by law. See Services not permitted by law in the General plan exclusions section for more information.

This plan provides coverage for many kinds of covered services, such as a doctor’s care and hospital stays, but some services aren’t covered at all or are limited. For other services, the plan pays more of the expense. For example:

Physician care generally is covered but physician care for cosmetic surgery is never covered. This is an exclusion.

Home health care is generally covered but may only be covered up to a set number of visits per year.

This is a limitation.

Your provider may recommend services that are considered experimental, investigational, or unproven services. But an experimental, investigational, or unproven service is not covered and is also an exclusion, unless it is recognized as part of an approved clinical trial when you have cancer or a terminal illness. See Clinical trials in the list of services below.

Preventive services. Usually the plan pays more, and you pay less. Preventive services are designed to help keep you healthy, supporting you in achieving your best health. To find out what these services are, see the Preventive care section in the list of services below. To find out how much you will pay for these services, see Preventive care in your schedule of benefits.

Some services require precertification from us. For more information see the How your plan works – Medical necessity and precertification requirements section.

The covered services and exclusions below appear alphabetically to make it easier to find what you’re looking for. If a service isn’t listed here as a covered service or is listed as not covered under a specific service, it still may be covered. If you have questions, ask your provider or contact us. You can find out about limitations for covered services in the schedule of benefits.

Acupuncture Covered services include acupuncture services provided by a physician if the service is provided as a form of anesthesia in connection with a covered surgical procedure.

The following are not covered services:

Acupuncture, other than for anesthesia Acupressure

Ambulance services An ambulance is a vehicle staffed by medical personnel and equipped to transport an ill or injured person by ground, air, or water.

Emergency

Covered services include emergency transportation when your condition is unstable and requires medical supervision and rapid transport. These emergency ambulance services are limited to transportation by a licensed ambulance:

To the first facility to provide emergency services From one facility to another if the first can’t provide the emergency services you need

Non-emergency Covered services also include non-emergency transportation when an ambulance is the only safe way to transport you. These non-emergency ambulance services are limited to transportation by a licensed ambulance:

To the nearest facility able to treat your condition From a facility to your home by ground ambulance

The following are not covered services:

Ambulance services for non-emergency transportation Ambulance services for routine transportation to receive outpatient or inpatient services

Applied behavior analysis Covered services include applied behavior analysis for a diagnosis of autism spectrum disorder. Applied behavior analysis is a process of applying interventions that:

Systematically change behavior Are responsible for observable improvements in behavior

Autism spectrum disorder Autism spectrum disorder is defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association.

Covered services include services and supplies provided by a physician or behavioral health provider for:

The diagnosis and treatment of autism spectrum disorder Physical, occupational, and speech therapy associated with the diagnosis of autism spectrum disorder

Behavioral health Mental health treatment Covered services include the treatment of mental health disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider including:

Inpatient room and board at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies related to your condition that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility

Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:

‒ Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)

‒ Individual, group, and family therapies for the treatment of mental health disorders ‒ Other outpatient mental health treatment such as:

o Partial hospitalization treatment provided in a facility or program for mental health treatment provided under the direction of a physician o Intensive outpatient program provided in a facility or program for mental health treatment provided under the direction of a physician o Skilled behavioral health services provided in the home, but only when all of the following criteria are met:

You are homebound Your physician orders them The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home The skilled behavioral health care is appropriate for the active treatment of a condition, illness, or disease o Electro-convulsive therapy (ECT) o Transcranial magnetic stimulation (TMS) o Psychological testing o Neuropsychological testing o Observation o Peer counseling support by a peer support specialist (including telemedicine consultation)

Substance related disorders treatment Covered services include the treatment of substance related disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider as follows:

Inpatient room and board, at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility.

Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:

- Office visits to a physician or behavioral health provider such as a psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)

- Individual, group, and family therapies for the treatment of substance related disorders

- Other outpatient substance related disorders treatment such as:

o Partial hospitalization treatment provided in a facility or program for treatment of substance related disorders provided under the direction of a physician o Intensive outpatient program provided in a facility or program for treatment of substance related disorders provided under the direction of a physician o Skilled behavioral health services provided in the home, but only when all of the following criteria are met:

You are homebound Your physician orders them The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home The skilled behavioral health care is appropriate for the active treatment of a condition, illness, or disease o Ambulatory or outpatient detoxification which includes outpatient services that monitor withdrawal from alcohol or other substances, including administration of medications o Observation o Peer counseling support by a peer support specialist (including telemedicine consultation)

Behavioral health important note:

A peer support specialist serves as a role model, mentor, coach, and advocate. Peer support must be supervised by a behavioral health provider.

Clinical trials Routine patient costs Covered services include routine patient costs you have from a provider in connection with participation in an approved clinical trial as defined in the federal Public Health Service Act, Section 2709.

The following are not covered services:

Services and supplies related to data collection and record-keeping needed only for the clinical trial Services and supplies provided by the trial sponsor for free The experimental intervention itself (except Category B investigational devices and promising experimental or investigational interventions for terminal illnesses in certain clinical trials in accordance with our policies)

Experimental or investigational therapies Covered services include drugs, devices, treatments, or procedures from a provider under an “approved clinical trial” only when you have cancer or a terminal illness. All of the following conditions must be met:

Standard therapies have not been effective or are not appropriate We determine you may benefit from the treatment

An approved clinical trial is one that meets all of these requirements:

The Food and Drug Administration (FDA) has approved the drug, device, treatment, or procedure to be investigated or has granted it investigational new drug (IND) or group c/treatment IND status, when this is required

The clinical trial has been approved by an institutional review board that will oversee it The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal organization and:

- It conforms to standards of the NCI or other applicable federal organization

- It takes place at an NCI-designated cancer center or at more than one institution

You are treated in accordance with the procedures of that study

Durable medical equipment (DME) Covered services are DME and the accessories needed to operate it when:

Made to withstand prolonged use Mainly used in the treatment of illness or injury Suited for use in the home Not normally used by people who do not have an illness or injury Not for altering air quality or temperature Not for exercise or training

Your plan only covers the same type of DME that Medicare covers. But, there are some DME items Medicare covers that your plan does not.

Covered services include the expense of renting or buying DME and accessories you need to operate the item from a DME supplier. If you purchase DME, that purchase is only covered if you need it for long-term use.

Covered services also include:

One item of DME for the same or similar purpose Repairing DME due to normal wear and tear A new DME item you need because your physical condition has changed Buying a new DME item to replace one that was damaged due to normal wear, if it would be cheaper than repairing it or renting a similar item

The following are not covered services:

Communication aid Elevator Maintenance and repairs that result from misuse or abuse Massage table Message device (personal voice recorder) Over bed table Portable whirlpool pump Sauna bath Telephone alert system Vision aid Whirlpool

Emergency services When you experience an emergency medical condition, you should go to the nearest emergency room. You can also dial 911 or your local emergency response service for medical and ambulance help.

Covered services include only outpatient services to evaluate and stabilize an emergency medical condition in a hospital emergency room. You can get emergency services from network or out-of-network providers.

Your coverage for emergency services will continue until the following conditions are met:

You are evaluated and your condition is stabilized and Your attending physician determines that you are medically able to travel or be transported, by non-medical or non-emergency transportation, to another provider if you need more care

If your physician decides you need to stay in the hospital (emergency admission) or receive follow-up care, these are not emergency services. Different benefits and requirements apply. See the How your plan works – Medical necessity and precertification requirements section and the Coverage and exclusions section that fits your situation (for example, Hospital care or Physician services). You can also contact us or your network physician or primary care physician (PCP).

Non-emergency services If you go to an emergency room for what is not an emergency medical condition, the plan may not cover your expenses. See the schedule of benefits for more information.

Habilitation therapy services Habilitation therapy services are services needed to keep, learn or improve your skills and functioning for daily living (e.g., therapy for a child who isn’t walking or talking at the expected age). The services must follow a specific treatment plan, ordered by your physician. The services have to be performed by a:

Licensed or certified physical, occupational or speech therapist Hospital, skilled nursing facility or hospice facility Home health care agency Physician

Outpatient physical, occupational, and speech therapies Covered services include:

Physical therapy if it is expected to develop any impaired function Occupational therapy if it is expected to develop any impaired function Speech therapy if it is expected to develop speech function that resulted from delayed development

(Speech function is the ability to express thoughts, speak words and form sentences.)

The following are not covered services:

Services provided in an educational or training setting or to teach sign language Vocational rehabilitation or employment counseling

Hearing aids Hearing aid means:

Any wearable, non-disposable instrument or device designed to aid or make up for impaired hearing Parts, attachments, or accessories

Covered services include prescribed hearing aids and the following hearing aid services:

Audiometric hearing visit and evaluation for a hearing aid prescription performed by:

- A physician certified as an otolaryngologist or otologist

- An audiologist who:

o Is legally qualified in audiology o Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing

Association in the absence of any licensing requirements o Performs the exam at the written direction of a legally qualified otolaryngologist or otologist

Electronic hearing aids, installed in accordance with a prescription written during a covered hearing exam

Any other related services necessary to access, select, and adjust or fit a hearing aid

The following are not covered services:

Replacement of a hearing aid that is lost, stolen or broken Batteries or cords A hearing aid that does not meet the specifications prescribed for correction of hearing loss

Hearing exams Covered services include hearing exams for evaluation and treatment of illness, injury or hearing loss when performed by a hearing specialist.

The following are not covered services:

Hearing exams given during a stay in a hospital or other facility, except those provided to newborns as part of the overall hospital stay

Home health care Covered services include home health care provided by a home health care agency in the home, but only when all of the following criteria are met:

You are homebound Your physician orders them The services take the place of a stay in a hospital or a skilled nursing facility, or you are unable to receive the same services outside your home The services are a part of a home health care plan The services are skilled nursing services, home health aide services or medical social services, or are short-term speech, physical or occupational therapy Home health aide services are provided under the supervision of a registered nurse Medical social services are provided by or supervised by a physician or social worker

Skilled nursing services are services provided by a registered nurse or licensed practical nurse within the scope of their license.

If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent requirement may be waived to allow coverage for continuous skilled nursing services. See the schedule of benefits for more information on the intermittent requirement.

Short-term physical, speech, and occupational therapy provided in the home are subject to the same conditions and limitations imposed on therapy provided outside the home. See Rehabilitation services and Habilitation therapy services in this section and the schedule of benefits.

The following are not covered services:

Custodial care Services provided outside of the home (such as in conjunction with school, vacation, work, or recreational activities) Transportation

Hospice care Covered services include inpatient and outpatient hospice care when given as part of a hospice care program.

The types of hospice care services that are eligible for coverage include:

Room and board Services and supplies furnished to you on an inpatient or outpatient basis Services by a hospice care agency or hospice care provided in a hospital Psychological and dietary counseling Pain management and symptom control Bereavement counseling Respite care

Hospice care services provided by the providers below will be covered, even if the providers are not an employee of the hospice care agency responsible for your care:

A physician for consultation or case management A physical or occupational therapist A home health care agency for:

- Physical and occupational therapy

- Medical supplies

- Outpatient prescription drugs

- Psychological counseling

- Dietary counseling

The following are not covered services:

Funeral arrangements Pastoral counseling Financial or legal counseling including estate planning and the drafting of a will Homemaker services, caretaker services, or any other services not solely related to your care, which may include:

- Sitter or companion services for you or other family members

- Transportation

- Maintenance of the house

Hospital care Covered services include inpatient and outpatient hospital care. This includes:

Semi-private room and board (your plan will cover the extra expense of a private room when appropriate because of your medical condition)

Services and supplies provided by the outpatient department of a hospital, including the facility charge Services of physicians employed by the hospital Administration of blood and blood products

The following are not covered services:

All services and supplies provided in:

- Rest homes

- Any place considered a person’s main residence or providing mainly custodial or rest care

- Health resorts

- Spas

- Schools or camps

Infertility services Basic infertility Covered services include seeing a provider:

To diagnose and evaluate the underlying medical cause of infertility.

To do surgery to treat the underlying medical cause of infertility. Examples are endometriosis surgery or, for men, varicocele surgery.

Infertility services exclusions:

The following are not covered services:

All infertility services associated with or in support of an ovulation induction cycle while on injectable medication to stimulate the ovaries. This includes, but is not limited to, imaging, laboratory services, and professional services.

Intrauterine (IUI)/intracervical insemination (ICI) services.

All infertility services associated with or in support of an Advanced Reproductive Technology (ART) cycle. These include, but are not limited to:

- Imaging, laboratory services, and professional services

- In vitro fertilization (IVF)

- Zygote intrafallopian transfer (ZIFT)

- Gamete intrafallopian transfer (GIFT)

- Cryopreserved embryo transfers

- Gestational carrier cycles

- Any related services, products or procedures (such as intracytoplasmic sperm injection (ICSI) or ovum microsurgery).

Cryopreservation (freezing) and storage of eggs, embryos, sperm, or reproductive tissue.

Thawing of cryopreserved (frozen) eggs, sperm, or reproductive tissue.

All charges associated with or in support of surrogacy arrangements for you or the surrogate. A surrogate is a female carrying her own genetically related child with the intention of the child being raised by someone else, including the biological father.

Home ovulation prediction kits or home pregnancy tests.

The purchase of donor embryos, donor eggs or donor sperm.

Obtaining sperm from a person not covered under this plan.

Infertility treatment when a successful pregnancy could have been obtained through less costly treatment.

Infertility treatment when either partner has had voluntary sterilization surgery, with or without surgical reversal, regardless of post reversal results. This includes tubal ligation, hysterectomy and vasectomy only if obtained as a form of voluntary sterilization.

Infertility treatment when infertility is due to a natural physiologic process such as age related ovarian insufficiency (e.g., perimenopause, menopause) as measured by an unmedicated FSH level at or above 19 on cycle day two or three of your menstrual period or other abnormal testing results as outlined in Aetna’s infertility clinical policy.

Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists.

Jaw joint disorder treatment Covered services include the diagnosis and surgical treatment of jaw joint disorder by a provider, including:

The jaw joint itself, such as temporomandibular joint dysfunction (TMJ) syndrome The relationship between the jaw joint and related muscle and nerves, such as myofascial pain dysfunction (MPD)

The following are not covered services:

Non-surgical medical and dental services, and therapeutic services related to jaw joint disorder

Maternity and related newborn care Covered services include pregnancy (prenatal) care, care after delivery and obstetrical services. After your child is born, covered services include:

No less than 48 hours of inpatient care in a hospital after a vaginal delivery No less than 96 hours of inpatient care in a hospital after a cesarean delivery A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier

If the mother is discharged earlier, the plan will pay for 1 home visit after delivery by a health care provider.

Covered services also include services and supplies needed for circumcision by a provider.

The following are not covered services:

Any services and supplies related to births that take place in the home or in any other place not licensed to perform deliveries

Obesity surgery and services Obesity surgery is a type of procedure performed on people who are morbidly obese for the purpose of losing weight. Your physician will determine whether you qualify for obesity surgery.

Covered services include:

An initial medical history and physical exam Diagnostic tests given or ordered during the first exam Outpatient prescription drugs included under the Prescription drugs – outpatient section An obesity surgical procedure A multi-stage procedure when planned and approved by the plan Adjustments after an approved lap band procedure, including approved adjustments in an office or outpatient setting

The following are not covered services:

Weight management treatment Drugs intended to decrease or increase body weight, control weight or treat obesity except as described in the booklet.

Preventive care services for obesity screening and weight management interventions, regardless of whether there are other related conditions. This includes:

- Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food supplements, appetite suppressants and other medications

- Hypnosis, or other forms of therapy

Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or other forms of activity or activity enhancement

Oral and maxillofacial treatment (mouth, jaws and teeth) Covered services include the following when provided by a physician, dentist and hospital:

Cutting out:

- Cysts, tumors, or other diseased tissues

Cutting into gums and tissues of the mouth.

‒ Only when not associated with the removal, replacement or repair of teeth

Outpatient surgery Covered services include services provided and supplies used in connection with outpatient surgery performed in a surgery center or a hospital’s outpatient department.

Important note:

Some surgeries can be done safely in a physician’s office. For those surgeries, your plan will pay only for physician, PCP services and not for a separate fee for facilities.

The following are not covered services:

A stay in a hospital (see Hospital care in this section) Services of another physician for the administration of a local anesthetic

Physician services Covered services include services by your physician to treat an illness or injury. You can get services:

At the physician’s office In your home In a hospital From any other inpatient or outpatient facility By way of telemedicine

Important note:

For behavioral health services, all in-person, covered services with a behavioral health provider are also covered services if you use telemedicine instead.

Telemedicine may have a different cost share from other physician services. See your schedule of benefits.

Other services and supplies that your physician may provide:

Allergy testing and allergy injections Radiological supplies, services, and tests Immunizations that are not covered as preventive care

Preventive care Preventive covered services are designed to help keep you healthy, supporting you in achieving your best health through early detection. If you need further services or testing such as diagnostic testing, you may pay more as these services aren’t preventive. If a covered service isn’t listed here under preventive care, it still may be covered under other covered services in this section. For more information, see your schedule of benefits.

The following agencies set forth the preventive care guidelines in this section:

Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) United States Preventive Services Task Force (USPSTF) Health Resources and Services Administration American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents

These recommendations and guidelines may be updated periodically. When updated, they will apply to this plan. The updates are effective on the first day of the year, one year after the updated recommendation or guideline is issued.

For frequencies and limits, contact your physician or us. This information is also available at https://www.healthcare.gov/

Important note:

Gender-specific preventive care benefits include covered services described regardless of the sex you were assigned at birth, your gender identity, or your recorded gender.

https://www.healthcare.gov/

Breast-feeding support and counseling services Covered services include assistance and training in breast-feeding and counseling services during pregnancy or after delivery. Your plan will cover this counseling only when you get it from a certified breast-feeding support provider.

Breast pump, accessories and supplies Covered services include renting or buying equipment you need to pump and store breast milk.

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.

Counseling services Covered services include preventive screening and counseling by your health professional for:

Alcohol or drug misuse

- Preventive counseling and risk factor reduction intervention

- Structured assessment

Genetic risk for breast and ovarian cancer Obesity and healthy diet

- Preventive counseling and risk factor reduction intervention

- Nutritional counseling

- Healthy diet counseling provided in connection with hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease Sexually transmitted infection Tobacco cessation

- Preventive counseling to help stop using tobacco products

- Treatment visits

- Class visits

Family planning services – female contraceptives Covered services include family planning services as follows:

Counseling services provided by a physician or other provider on contraceptive methods. These will be covered when you get them in either a group or individual setting.

Contraceptive devices (including any related services or supplies) when they are prescribed, provided, administered, or removed by a health professional.

Voluntary sterilization including charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies. This also could include tubal ligation and sterilization implants.

The following are not preventive covered services:

Services provided as a result of complications resulting from a voluntary sterilization procedure and related follow-up care Any contraceptive methods that are only “reviewed” by the FDA and not “approved” by the FDA Male contraceptive methods, sterilization procedures or devices

Immunizations Covered services include preventive immunizations for infectious diseases.

The following are not preventive covered services:

Immunizations that are not considered preventive care, such as those required due to your employment or travel

Prenatal care Covered services include your routine pregnancy physical exams at the physician, PCP, OB, GYN or OB/GYN office. The exams include initial and subsequent visits for:

Anemia screening Blood pressure Chlamydia infection screening Fetal heart rate check Fundal height Gestational diabetes screening Gonorrhea screening Hepatitis B screening Maternal weight Rh incompatibility screening

Preventive care drugs Contraceptives (birth control) For females who are able to become pregnant, covered services include certain drugs and devices that the FDA has approved to prevent pregnancy. You will need a prescription from you provider and must fill it at a network pharmacy. At least one form of each FDA-approved contraception methods is a covered service. You can access a list of covered drugs and devices. See the Contact us section for how.

We also cover over-the-counter (OTC) and generic prescription drugs and devices for each of the methods identified by the FDA at no cost to you. If a generic prescription drug or device is not available for a certain method, you may obtain certain brand-name prescription drugs or devices for that method at no cost.

The following is not a covered service:

Brand-name prescription drug forms of contraception in each of the methods identified by the FDA

Important note:

You may qualify for a medical exception if your provider determines that the contraceptives covered as preventive care are not medically appropriate for you. Your provider may request a medical exception and submit the exception to us for review. If the exception is approved, the brand-name prescription drug contraceptive will be covered at 100%

Preventive care drugs and supplements Covered services include preventive care drugs and supplements, including OTC ones, as required by the ACA, when you have a prescription and it is filled at a network pharmacy.

Risk reducing breast cancer prescription drugs Covered services include prescription drugs used to treat people who are at an increased risk for breast cancer and a low risk for adverse medication side effects. You will need a prescription from your provider and have it filled at a network pharmacy.

Tobacco cessation prescription drugs Covered services include FDA-approved drugs and OTC aids and drugs to help stop the use of tobacco products, including nicotine replacement therapy. All OTC aids must be prescribed by a provider.

Routine cancer screenings Covered services include the following routine cancer screenings:

Colonoscopies including pre-procedure specialist consultation, removal of polyps during a screening procedure, and a pathology exam on any removed polyp

Digital rectal exams (DRE) Double contrast barium enemas (DCBE) Fecal occult blood tests (FOBT) Lung cancer screenings Mammograms Prostate specific antigen (PSA) tests Sigmoidoscopies

Routine physical exams A routine preventive exam is a medical exam given 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.

Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents.

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 on topics such as:

o Interpersonal and domestic violence o Sexually transmitted diseases o Human immune deficiency virus (HIV) infections

- High risk human papillomavirus (HPV) DNA testing for women

Covered services include:

Office visit to a physician Hearing screening Vision screening Radiological services, lab and other tests For covered newborns, an initial hospital checkup

Well woman preventive visits A routine well woman preventive exam is a medical exam given for a reason other than to diagnose or treat a suspected or identified illness or injury and also includes:

Office visit to a physician, PCP, OB, GYN or OB/GYN for services including Pap smears Preventive care breast cancer (BRCA) gene blood testing Screening for diabetes after pregnancy for women with a history of diabetes during pregnancy Screening for urinary incontinence

Prosthetic device A prosthetic device is a device that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of illness, injury or congenital defects.

Covered services include the initial provision and subsequent replacement of a prosthetic device that your physician orders and administers.

Coverage includes:

Instruction and other services (such as attachment or insertion) so you can properly use the device Repairing or replacing the original device you outgrow or that is no longer appropriate because your physical condition changed Replacements required by ordinary wear and tear or damage

If you receive a prosthetic device as part of another covered service, it will not be covered under this benefit.

The following are not covered services:

Orthopedic shoes and therapeutic shoes, unless the orthopedic shoe is an integral part of a covered leg brace Trusses, corsets, and other support items Repair and replacement due to loss, misuse, abuse or theft

Reconstructive breast surgery and supplies Covered services include all stages of reconstructive surgery by your provider and related supplies provided in an inpatient or outpatient setting only in the following circumstances:

Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an implant and areolar reconstruction. It also includes:

- Surgery on a healthy breast to make it symmetrical with the reconstructed breast

- Treatment of physical complications of all stages of the mastectomy, including lymphedema

- Prostheses

Reconstructive surgery and supplies Covered services include all stages of reconstructive surgery by your provider and related supplies provided in an inpatient or outpatient setting only in the following circumstances:

Your surgery is to implant or attach a covered prosthetic device.

Your surgery corrects a gross anatomical defect present at birth. The surgery will be covered if:

- The defect results in severe facial disfigurement or major functional impairment of a body part, and

- The purpose of the surgery is to improve function

Your surgery is needed because treatment of your illness resulted in severe facial disfigurement or major functional impairment of a body part, and your surgery will improve function.

Accidental injury to natural teeth Covered services also include the procedures or surgery to sound natural teeth, injured due to an accident and performed as soon as medically possible, when:

The teeth were stable, functional and free from decay or disease at the time of the injury The surgery or procedure returns the injured teeth to how they functioned before the accident

These accident-related dental services are limited to:

The first placement of a permanent crown or cap to repair a broken tooth The first placement of dentures or bridgework to replace lost teeth Orthodontic therapy to pre-position teeth

Short-term cardiac and pulmonary rehabilitation services Cardiac rehabilitation Covered services include cardiac rehabilitation services you receive at a hospital, skilled nursing facility or physician’s office, but only if those services are part of a treatment plan determined by your risk level and ordered by your physician.

Pulmonary rehabilitation Covered services include pulmonary rehabilitation services as part of your inpatient hospital stay if they are part of a treatment plan ordered by your physician. A course of outpatient pulmonary rehabilitation may also be covered if it is performed at a hospital, skilled nursing facility, or physician’s office, is used to treat reversible pulmonary disease states, and is part of a treatment plan ordered by your physician.

Short-term rehabilitation services Short-term rehabilitation services are services needed to restore or develop your skills and functioning for daily living. The services must follow a specific treatment plan, ordered by your physician. The services have to be performed by a:

Licensed or certified physical, occupational, or speech therapist Hospital, skilled nursing facility, or hospice facility Home health care agency Physician

Covered services include:

Spinal manipulation to correct a muscular or skeletal problem. Your provider must establish or approve a treatment plan that details the treatment and specifies frequency and duration.

Cognitive rehabilitation, physical, occupational, and speech therapy Covered services include:

Physical therapy, but only if it is expected to significantly improve or restore physical functions lost as a result of an acute illness, injury, or surgical procedure

Occupational therapy, but only if it is expected to do one of the following:

- Significantly improve, develop, or restore physical functions you lost as a result of an acute illness, injury, or surgical procedure

- Help you relearn skills so you can significantly improve your ability to perform the activities of daily living on your own Speech therapy, but only if it is expected to do one of the following:

- Significantly improve or restore lost speech function or correct a speech impairment resulting from an acute illness, injury, or surgical procedure

- Improve delays in speech function development caused by 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 rehabilitation associated with physical rehabilitation, but only when:

- Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or encephalopathy

- The therapy is coordinated with us as part of a treatment plan intended to restore previous cognitive function

Short-term physical, speech and occupational therapy services provided in an outpatient setting are subject to the same conditions and limitations for outpatient short-term rehabilitation services. See the Short-term rehabilitation services section in the schedule of benefits.

The following are not covered services:

Services provided in an educational or training setting or to teach sign language Vocational rehabilitation or employment counseling

Skilled nursing facility Covered services include inpatient skilled nursing facility care. This includes:

Room and board, up to the semi-private room rate Services and supplies provided during a stay in a skilled nursing facility

Specialty prescription drugs Covered services include specialty prescription drugs when they are:

Purchased by your provider Injected or infused by your provider in an outpatient setting such as:

- A freestanding outpatient facility

- The outpatient department of a hospital

- A physician in the office A home care provider in your home

Telemedicine Covered services include telemedicine consultations when provided by a physician, specialist, behavioral health provider or other telemedicine provider acting within the scope of their license.

Covered services for telemedicine consultations are available from a number of different kinds of providers under your plan. Log in to your member website at https://www.aetna.com/ to review our telemedicine provider listing and contact us to get more information about your options, including specific cost sharing amounts.

The following are not covered services:

Telephone calls Telemedicine kiosks Electronic vital signs monitoring or exchanges (e.g. Tele-ICU, Tele-stroke)

Tests, images and labs - outpatient Diagnostic complex imaging services Covered services include:

Computed tomography (CT) scans, including for preoperative testing Magnetic resonance imaging (MRI) including magnetic resonance spectroscopy (MRS), magnetic resonance venography (MRV) and magnetic resonance angiogram (MRA) Nuclear medicine imaging including positron emission tomography (PET) scans Other imaging service where the billed charge exceeds $500

Complex imaging for preoperative testing is covered under this benefit.

Diagnostic lab work Covered services include:

Lab Pathology Other tests

These are covered only when you get them from a licensed radiology provider or lab.

https://www.aetna.com/

Diagnostic x-ray and other radiological services Covered services include x-rays, scans and other services (but not complex imaging) only when you get them from a licensed radiology provider. See Diagnostic complex imaging services above for more information.

Therapies – chemotherapy, GCIT, infusion, radiation

Chemotherapy Covered services for chemotherapy depend on where treatment is received. In most cases, chemotherapy is covered as outpatient care. However, your hospital benefit covers the initial dose of chemotherapy after a cancer diagnosis during a hospital stay.

Gene-based, cellular and other innovative therapies (GCIT) Covered services include GCIT provided by a physician, hospital or other provider.

GCIT covered services include:

Cellular immunotherapies.

Genetically modified oncolytic viral therapy.

Other types of cells and tissues from and for use by the same person (autologous) and cells and tissues from one person for use by another person (allogenic) for certain therapeutic conditions.

Human gene-based therapy that seeks to change the usual function of a gene or alter the biologic properties of living cells for therapeutic use. Examples include therapies using:

Luxturna® (Voretigene neparvovec) Zolgensma® (Onasemnogene abeparvovec-xioi) Spinraza® (Nusinersen)

Products derived from gene editing technologies, including CRISPR-Cas9.

Oligonucleotide-based therapies. Examples include:

Antisense. An example is Spinraza.

siRNA.

mRNA.

microRNA therapies.

Facilities/provider for gene-based, cellular and other innovative therapies We designate facilities to provide GCIT services or procedures. GCIT physicians, hospitals and other providers are GCIT-designated facilities/providers for Aetna and CVS Health.

Important note:

You must get GCIT covered services from the GCIT-designated facility/provider. If there are no GCIT-designated facilities/providers assigned in your network, it’s important that you contact us so we can help you determine if there are other facilities that may meet your needs. If you do not get your GCIT services at the facility/provider we designate, they will not be covered services.

The following are not covered services unless you receive prior written approval from us:

GCIT services received at a facility or with a provider that is not a GCIT-designated facility/provider All associated services when GCIT services are not covered. Examples include infusion, laboratory, radiology, anesthesia, and nursing services.

Please refer to the How your plan works – Medical necessity and precertification requirements section.

Key Terms To help you understand this section, here are some key terms we use.

Cellular Relating to or consisting of living cells.

GCIT

Any Services that are:

Gene-based Cellular and innovative therapeutics

We call these “GCIT services”.

They have a basis in genetic/molecular medicine and are not covered under the Institutes of Excellence™ (IOE) programs.

Gene A unit of heredity which is transferred from a parent to child and is thought to determine some feature of the child.

Molecular Relating to or consisting of…