ESBD_521004_1780004979249_Exhibit A-16 Plan Summaries.pdf

Open Access Aetna Select medical plan

Booklet Prepared for:

Employer: Travis County Healthcare District d/b/a- Central Health Contract number: MSA-0285663 Control number: 0181116 Plan name: Open Access Aetna Select Booklet - AWH Seton ACO Booklet: 2 Plan effective date: January 1, 2026 Plan issue date: January 16, 2026

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 appeal 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 plan. 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 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.

For covered services under the outpatient prescription drug plan:

• You need a prescription from the prescribing provider

• You need to show your ID card to the network pharmacy when you get a prescription filled

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. You can find out about limitations for covered services in the schedule of benefits.

• 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 Preventive care 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.

Important note:

• We develop and maintain clinical policy bulletins that describe the generally accepted standards of medical practice, credible scientific evidence, and prevailing clinical guidelines that support our decisions regarding specific services. We use these bulletins and other resources to help guide individualized coverage decisions under our plans and to determine whether an intervention is medically necessary, experimental, investigational, or unproven. They are subject to change. You can find these bulletins and other information at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html. You can also contact us. See the Contact us section for how.

• We cover medically necessary, sex-specific covered services regardless of identified gender.

https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html

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 is 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, except as described in the section above

• 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. A peer support specialist 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

Diabetic services, supplies, equipment, and self-care programs Covered services include:

• Services

- Foot care to minimize the risk of infection

• Supplies

- Injection devices including syringes, needles and pens

- Test strips - blood glucose, ketone and urine

- Blood glucose calibration liquid

- Lancet devices and kits

- Alcohol swabs

• Equipment

- External insulin pumps and pump supplies

- Blood glucose monitors without special features, unless required due to blindness

- Continuous glucose monitors

• Prescribed self-care programs with a health care provider certified in diabetes self-care training

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

• Replacement parts or repairs for a hearing aid

• 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

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

• 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.

• For artificial insemination, which includes intrauterine (IUI)/intracervical (ICI) insemination.

See the Coverage and exclusions-Prescription drugs – outpatient section for information on coverage of infertility prescription drugs.

Infertility services exclusions:

• 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.

• Infertility medication. See the Coverage and exclusions-Prescription drugs – outpatient section for information on coverage of infertility prescription drugs.

• 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).

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)

• 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

Nutritional support For purposes of this benefit, “low protein modified food product” means foods that are specifically formulated to have less than one gram of protein per serving and are intended to be used under the direction of a physician for the dietary treatment of any inherited metabolic disease. Low protein modified food products do not include foods that are naturally low in protein.

Covered services include formula and low protein modified food products ordered by a physician for the treatment of phenylketonuria or an inherited disease of amino and organic acids.

The following are not covered services:

Any food item, including:

• Infant formulas

• Nutritional supplements

• Vitamins

• Medical foods

• Other nutritional items

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.

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.

• 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

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

Prescription drugs - outpatient Read this section carefully. This plan does not cover all prescription drugs and some coverage may be limited.

This doesn’t mean you can’t get prescription drugs that aren’t covered; you can, but you have to pay for them yourself. For more information about prescription drug benefits, including limits, see the schedule of benefits.

A pharmacy may refuse to fill or refill a prescription when, in the professional judgement of the pharmacist, it should not be filled or refilled.

Your plan provides standard safety checks to encourage safe and appropriate use of medications. These checks are intended to avoid adverse events and align with the medication’s U.S. Food and Drug Administration (FDA) approved prescribing information and current published clinical guidelines and treatment standards. These checks are routinely updated as new medications come to market and as guidelines and standards are updated.

Covered services are based on the drugs in the drug guide. The drug guide contains a formulary exclusions list.

This list is subject to change. We exclude prescription drugs listed on the formulary exclusions list unless we approve a medical exception. See the How your plan works – Medical necessity, referral, and, precertification requirements – Requesting a medical exception section for more information on medical exceptions, or just contact us.

Your provider can give you a prescription in different ways including:

• A written prescription that you take to a network pharmacy

• Calling or e-mailing a prescription to a network pharmacy

• Submitting the prescription to a network pharmacy electronically

The pharmacy may substitute a generic prescription drug for a brand-name prescription drug. Your cost share may be less if you use a generic drug when it is available.

Any prescription drug made to work beyond one month shall require the copayment amount that equals the expected duration of the medication.

Prescription drug synchronization If you are prescribed multiple maintenance medications and would like to have them each dispensed on the same fill date for your convenience, your network pharmacy may be able to coordinate that for you. This is called synchronization. We will apply a prorated daily cost share rate, to a partial fill of a maintenance drug, if needed, to synchronize your prescription drugs.

How to access network pharmacies A network pharmacy will submit your claim. You will pay your cost share to the pharmacy.

You can find a network pharmacy either online or by phone. See the Contact us section for how.

You may go to any of our network pharmacies.

If you don’t get your prescriptions at a network pharmacy, it will not be a covered service under the plan.

Pharmacy types Retail pharmacy For short-term medications, a retail pharmacy may be used for up to a 30 day supply of a prescription drug.

For long-term medications, an Extended Day Supply (EDS) network retail pharmacy may be used for up to a 90-day supply of prescription drugs. To locate a participating Extended Day Supply (EDS) network retail pharmacy in your area, refer to Aetna’s website, www.aetna.com, to review the list of network retail pharmacies. The list may be updated from time to time.

Mail order pharmacy The drugs available through mail order are maintenance drugs that you take on a regular basis for a chronic or long-term medical condition. A mail order pharmacy may be used for up to a 90 day supply of a prescription drug.

Prescriptions can be filled at a network mail order pharmacy.

Specialty pharmacy A specialty pharmacy may be used for up to a 30 day supply of a specialty prescription drug. You can view the list of specialty prescription drugs. See the Contact us section for how.

All specialty prescription drug fills including the first fill must be filled at a network specialty pharmacy unless it is an urgent situation.

Plan copayment assistance program You will be automatically enrolled in your plan’s copayment assistance program. You may opt out of the program by contacting the plan’s program administrator at the telephone number shown, below.

The plan’s copayment assistance program will assist you by helping you sign up for programs offered by drug makers which are designed to lessen the cost of their specialty prescription drugs. Some drug makers have specific enrollment requirements that must be satisfied to qualify for their program. If you are taking a specialty prescription drug included in the plan’s copayment assistance program, the plan’s program administrator will contact you to provide the specific information needed to participate in that program.

With the plan’s copayment assistance program for covered specialty prescription drugs you will pay no cost share.

If you choose to not use the program, or don’t complete any participation requirements of the program, then you will pay a cost share.

The plan’s copayment assistance program administrator can be reached at 1-800-578-4403 to address any questions regarding the program.

Your cost share for specialty prescription drugs under the plan’s copayment assistance program, will not count toward your deductible or maximum out-of-pocket limit, if you have them in your plan, unless the specialty prescription drug is an essential health benefit. This includes cost shares that you or the plan’s copayment assistance program pay.

Utilization review Prescription drugs covered by this plan are subject to misuse, waste, or abuse utilization review by us, your provider, and/or your network pharmacy. The outcome of this review may include:

• Limiting coverage of a drug to one prescribing provider or one network pharmacy

• Quantity, dosage or day supply limits

• Requiring a partial fill or denial of coverage

When the pharmacy you use leaves the network Sometimes a pharmacy might leave the network. If this happens, you will have to get your prescriptions filled at another network pharmacy. You can use your provider directory or call us to find another network pharmacy in your area.

How to get an emergency prescription filled You may not have access to a network pharmacy in an emergency or urgent situation. If you must fill a prescription in one of these situations, you may obtain your prescription from an out-of-network pharmacy.

The out-of-network pharmacy may ask you to pay the full cost of the prescription. When you pay the full cost of the prescription at an out-of-network pharmacy:

• You can fill out and send a prescription drug refund form to us, including all itemized pharmacy receipts

• Coverage will be limited to items obtained in connection with the emergency or urgent situation

• Submission of the refund form doesn’t guarantee a refund. If approved, you will be reimbursed the cost of the prescription less your network cost share

Other covered services Abortion drugs Covered services include prescription drugs used for elective termination of pregnancy.

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 your provider and must fill it at a network pharmacy. At least one form of each FDA-approved contraception method 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 method of birth control approved by the FDA at no cost to you. If a generic drug or device is not available for a certain method, we will cover the brand-name prescription drug or device at no cost share.

Preventive contraceptives important note:

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

Diabetic supplies Covered services include but are not limited to the following:

• Alcohol swabs

• Blood glucose calibration liquid

• Diabetic syringes, needles and pens

• Continuous glucose monitors

• Insulin infusion disposable pumps

• Lancet devices and kits

• Test strips for blood glucose, ketones, urine

• Blood glucose meters and insulin pumps

See the Diabetic services, supplies, equipment, and self-care programs section for medical covered services.

Immunizations Covered services include preventive immunizations as required by the ACA when given by a network pharmacy.

You can find a participating network pharmacy by contacting us. Check with the pharmacy before you go to make sure the vaccine you need is in stock. Not all pharmacies carry all vaccines.

Preventive care drugs and supplements Covered services include preventive care drugs and supplements, including OTC ones, as required by the ACA.

Risk reducing breast cancer prescription drugs Covered services include prescription drugs used to treat people who are at:

• Increased risk for breast cancer

• Low risk for medication side effects

Tobacco cessation prescription and OTC drugs Covered services include FDA approved prescription and OTC drugs to help stop the use of tobacco products.

You must receive a prescription from your provider and submit the prescription to the pharmacy for processing.

Prescription drug exclusions:

• Allergy sera and extracts given by injection

• Any services related to providing, injecting or application of a drug

• Compounded prescriptions containing bulk chemicals not approved by the FDA including compounded bioidentical hormones, unless we have approved a medical exception

• Cosmetic drugs including medication and preparations used for cosmetic purposes

• Devices, products and appliances unless listed as a covered service

• Drugs or medications

- Administered or entirely consumed at the time and place they are prescribed or provided unless listed in the drug guide or we have approved a medical exception

- Which do not require a prescription by law, even if a prescription is written, unless listed as a covered service or we have approved a medical exception

- That are therapeutically the same or an alternative to a covered prescription drug, unless we approve a medical exception

- Not approved by the FDA or not proven safe or effective

- Provided under your medical plan while inpatient at a healthcare facility

- Recently approved by the FDA but not reviewed by our Pharmacy and Therapeutics Committee, unless we have approved a medical exception

- That includes vitamins and minerals unless recommended by the United States Preventive Services

Task Force (USPSTF)

- That are used to treat sexual dysfunction, enhance sexual performance or increase sexual desire, including drugs, implants, devices or preparations to correct or enhance erectile function, enhance sensitivity or alter the shape or appearance of a sex organ unless listed as a covered service

- That are indicated or used for the purpose of weight gain or loss including but not limited to stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food or food supplements, non-prescription appetite suppressants or other medications unless listed as a covered service

- That are drugs or growth hormones used to stimulate growth and prescribed only to treat idiopathic short stature

• Duplicative drug therapy; for example, two antihistamines for the same condition

• Genetic care including:

- Any treatment, device, drug, service or supply to alter the body’s genes, genetic makeup or the expression of the body’s genes unless listed as a covered service

• Immunizations related to travel or work

• Immunization or immunological agents unless listed as a covered service

• Implantable drugs and associated devices unless listed as a covered service

• Infertility:

- Prescription drugs used primarily for the treatment of infertility

• Injectables including:

- Any charges for the administration or injection of prescription drugs

- Needles and syringes except for those used for insulin administration

- Any drug which, due to its characteristics as determined by us, must typically be administered or supervised by a qualified provider or licensed certified health professional in an outpatient setting, with the exception of Depo Provera and other injectable drugs for contraception, unless listed in the drug guide or we have approved a medical exception

• Off-label drug use except for indications recognized through peer-reviewed medical literature

• Prescription drugs:

- That are ordered by a dentist or prescribed by an oral surgeon in relation to the removal of teeth or prescription drugs for the treatment of a dental condition

- That are considered oral dental preparations and fluoride rinses except pediatric fluoride tablets or drops as specified on the plan’s drug guide

- That are being used or abused in a manner that is determined to be furthering an addiction to a habit-forming substance, the use of or intended use of which is illegal, unethical, imprudent, abusive, not medically necessary or otherwise improper and drugs obtained for use by anyone other than the member as identified on the ID card

• Prescription drugs used only for the purpose of weight loss

• Replacement of lost or stolen prescriptions

• Test agents except diabetic test agents

• Tobacco cessation drugs, unless recommended by the USPSTF

• We reserve the right to exclude:

- A manufacturer’s product when the same or similar drug (one with the same active ingredient or same therapeutic effect), supply or equipment is on the plan’s drug guide

- Any dosage or form of a drug when the same drug is available in a different dosage or form on the plan’s drug guide

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/

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.

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.

https://www.healthcare.gov/

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

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

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

• Breast cancer screenings including initial screening mammograms, and if necessary to complete the screening process, additional imaging (e.g., MRI, ultrasound, mammography) and pathology evaluation

• 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…