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1 Dear University of Virginia Faculty and Staff: Welcome to Aetna! One of the nation's leading health benefits companies, Aetna provides members with information and resources to help you make smart decisions about your health care. We are here to help you manage the complex world of health care and insurance benefits. Online member tools We provide access to online tools DocFind and Aetna Navigator, your secure member website that provide quick and easy access to network providers and facilities, as well as information you need to stay healthy. DocFind is a custom website for University of Virginia Health Plan members. It provides real-time resources to find core and/or Aetna in-network (national) doctors and facilities. Always use network providers and facilities for the highest level of benefits coverage under the University of Virginia Health Plan. Informed Health Line Talk to a registered nurse 24 hour, 365 days, a year nurseline available toll free to you at: You can call as many times as you need- at no additional cost. Your covered family members can use it, too! To start using DocFind today, go to Registration is not required. You can search for providers by: City, state, zip code Specialty Hospital relationship Provider name Gender You can also access additional provider information, such as: Medical schools attended Board certification status Languages spoken Other resources include: Office locations Handicap access Maps and driving directions Claim forms Medical plan summary (SPD) Aetna Navigator, your secure Aetna member website, provides a wide array of programs and services to help you manage your health and your health care costs. Because this is a secure site for members, registration is required, but only takes a few moments. Visit your Aetna member website to: Check claims status Request a new ID card Use the cost-of-care tools to help you estimate the cost of your health care services Access the Health Information Guide and other resources to help you make smart choices about your health care Register for Aetna Navigator Once you are enrolled in the University of Virginia Health Plan, you can start taking advantage of all Aetna has to offer by registering online with your Aetna member website: Go to Select Member Log In from the left navigation.

2 Select Register. You will need your member ID (from your Aetna ID card) or your Social Security number. If you are a dependent, you will have to provide the subscriber's ID number or Social Security number, the subscriber's first and last name, date of birth, and zip code. What else is available to you? Included in this package are brochures highlighting other key programs and services that are now available to you as an Aetna member, such as, maternity management, Note that enrollment and continued participation in the Beginning Right Maternity Program may waive the inpatient copayment for your baby depending on the medical option in which you are enrolled. Enrollment in the maternity program must occur within the first 16 weeks of pregnancy to receive the copayment waiver. When you participate in this program, all your care is coordinated by your Ob/Gyn and Aetna case managers. Participation in this program results in the waiver of the inpatient hospital newborn cost-sharing if you are enrolled in Choice Health and waiver of the in-network deductible for the newborn if you are enrolled in Value Health. Members enrolled in Basic Health or Basic Health Wage must adhere to the regulations of a high deductible health plan and are ineligible for a waived deductible. Hoo s Well Active Health Management, our partner in health, provides care management and lifestyle coaching programs as well as online wellness programs. For more information, please contact ActiveHealth at or go to Questions If you have questions, please contact Member Services at or for Pharmacy questions. You may also visit to find general information or to log in to your Aetna member website. Again, welcome to Aetna. We look forward to helping you improve your health. Please take advantage of all the tools and resources we offer. Sincerely, Aetna Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna) Aetna Inc.

3 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions You pick your doctor, no referrals needed Open Choice Plan L (8/14)

4 A health insurance plan designed to meet your needs Our Open Choice plan lets you visit any doctor you choose. And you do not need a referral when you visit one. The plan also gives you access to tools, tips, programs and services. Use them. They can help you find network doctors, estimate costs and more. Looking for your exact copay amounts? Or what your plan covers and doesn t cover? This booklet gives a general idea of how your Aetna health plan works and how to get the most out of it. For details like copays and what s covered, check your plan documents. They should be in your enrollment kit. If you do not have them, ask your employer. The options Pick your doctor How it works Network option Go to any doctor in the network. No referrals required. Network doctors contract with Aetna to offer rates that are often much lower than their regular fees. This helps you save. Your network doctor will: Provide care Get approval from us before giving you certain services* File claims for you You may have a deductible to pay first. This is the amount you pay each year before your plan begins to pay. You then pay a portion of your doctor s charges. This could be in the form of a copay (a fixed amount) or coinsurance (a percentage). This option typically costs you less. Out-of-network option Visit any licensed doctor or specialist without a referral. A specialist is a doctor who focuses only on treating certain conditions or diseases. For example, a dermatologist treats skin conditions. A cardiologist treats heart problems. You may have to: Get approval from Aetna before receiving certain services* Pay the full amount at the time of service File your own claims We will process your claim and reimburse you based on your employer s specific plan and benefits details. For example, if you have not met your deductible yet, that will be subtracted from your reimbursement amount. As will any copay or coinsurance you owe. Note: Your out-of-network deductible is usually higher than the deductible you need to pay when you see a network doctor. Check your plan documents for your plan s details. Your out-of-pocket costs are typically higher when you see an out-of-network doctor. *In Texas, this approval is known as pre-service utilization review and is not verification as defined by Texas law. In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. Health insurance plans are offered, underwritten and/or administered by Aetna Life Insurance Company (Aetna).

5 Take advantage of all your plan has to offer Finding a network doctor is easy Use our online directory. You can find doctors by specialty and location. You ll also find maps, directions and more. You can even look for doctors who speak your language. Visit to get started. Or get a printed directory. If you are already an Aetna member, call Member Services to get one. The toll-free number is on your Aetna ID card. If you re not an Aetna member yet or haven t received your ID card call AETNA ( ). Sign up for your members-only website When you re an Aetna member, you get tools and resources to help you manage your health and your benefits. All of your plan information and cost-saving tools are in one place your secure member website. You just need to sign up. Register at And then log in anytime. Meet Ann, your virtual assistant Ann can help you sign up for your secure member website. She can even help you find a doctor, estimate the cost of services, answer questions about claims, ID cards and more. She never sleeps, so chat with her anytime. Here s a way to estimate costs once you enroll Our Member Payment Estimator lets you compare and estimate costs** for office visits, tests and surgeries. This online tool factors in any deductible, coinsurance and copays that are part of your plan, plus Aetna s contracted rates. You can see how much you ll have to pay and how much Aetna will pay. To use the estimator tool, go to and log in to your secure member website. For help over the phone You can use our automated phone system to order an ID card or ask for a claim form and mailing address. The system works with your voice and your phone s touch tone (when you need privacy). You can also speak to Member Services anytime during regular business hours. For either option, the toll-free number is on your Aetna ID card. You re mobile so are we. So use your smartphone when you re on the go. ** Estimated costs not available in all markets. The tool gives you an estimate of what you would owe for a particular service based on your plan at that very point in time. Actual costs may differ from the estimate if, for example, claims for other services are processed after you get your estimate but before the claim for this service is submitted. Or, if the doctor or facility performs a different service at the time of your visit.

6 Your doctor. Your choice. Enroll today. Find what you need wherever, whenever The Aetna Mobile app puts our most popular online features at your fingertips. It s available for iphone and Android mobile devices. Visit If you require language assistance from an Aetna representative, please call the Member Services number located on your ID card, and you will be connected with the language line if needed; or you may dial direct at (140 languages are available. You must ask for an interpreter.) TDD (hearing impaired only). Si requiere la asistencia de un representante de Aetna que hable su idioma, por favor llame al número de Servicios al Miembro que aparece en su tarjeta de identificación y se le comunicará con la línea de idiomas si es necesario; de lo contrario, puede llamar directamente al (140 idiomas disponibles. Debe pedir un intérprete.) TDD (sólo para las personas con impedimentos auditivos). This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Apple, the Apple logo and iphone are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. Android and Google Play are trademarks of Google Inc. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Policy forms issued in Oklahoma include: GR-23 and/or GR-29/GR-29N Aetna Inc L (8/14)

7 It s not just health information. It s health information that matters to me. Great news! As part of your health benefits, you re automatically a member of MyActiveHealth.com. MyActiveHealth SM is a secure, online site that has all the health information that s important to YOU in one convenient place. There s even a Personal Health Record (PHR) where you can store all your health data and medical history for easy access. At MyActiveHealth, your health information works hard to help you take better care of yourself. And that s just the beginning, because the site is also your personal gateway to lots of other great health programs and services. You can log on 24/7 and start using the wide range of helpful tools and resources at your disposal. You ll even have a homepage that you can design around your preferences. And the best part is, none of it will cost you a thing. No kidding! MyActiveHealth is part of the benefits you already get. Go to right now to get started! Just a few of the things you can do at MyActiveHealth.com: Create reminders of doctors appointments and record them on a calendar. Use any computer to access your secure Personal Health Record and share health information, even at the doctor s office. See the most important things you can do for your health and take action on them. Listen to a podcast, watch a video or print out materials on health topics of interest to you. Get the latest news on issues important to your health. Find out about resources and programs your health plan makes available to you. Check potential drug interactions. Find and print out recipes for great-tasting, healthy eating.

8 If you have one of these long-term health conditions, you can work with a personal nurse coach at no extra cost. Active Disease ManagementSM Arthritis Asthma Blood clots Breast cancer Chronic back pain Chronic hepatitis B or C Chronic kidney disease Chronic neck pain Colon cancer COPD Crohn s disease Cystic fibrosis Diabetes Disease of leg arteries/pad GERD/gastric reflux disease Heart attack and angina Heart failure High blood pressure High cholesterol HIV Kidney failure Leukemia Lung cancer Lupus Lymphoma Migraines Osteoporosis Overweight/obesity Parkinson s disease Prostate cancer Seizures Sickle cell anemia Stomach ulcers Stroke Ulcerative colitis Programs are available for children and teens with the following conditions Asthma Diabetes Cystic fibrosis High blood pressure Sickle cell anemia Weight management/obesity You may be contacted and invited to participate. Or you can call right now and join- Call , Monday-Friday, 8:00am to 8:00pm, EST and Saturday, 9:00am to 2:00pm, EST. or go to If you feel like a long-term health condition is holding you back, give Active Disease Management a try. It could be the help you need to start getting the most out of life. Scan the QR code into your smartphone and take the first step to a better life. Now that I have a nurse coach, I m feeling better than ever! Don t let a chronic health condition stop you. A nurse coach can help you live life to the fullest. AHM130143_DM_Bro_Master_WC.indd 1-2 5/7/13 10:00 PM

9 Coaching is the heart of Active Disease Management. The challenging thing about a chronic or long-term health condition is just like the name says it s long-term. It s something you have to deal with every day. The good news is, most chronic conditions can be managed so they cause minimal interference with your daily life. That s where Active Disease Management can really help. Active Disease Management is a complete program that helps you understand and manage your health. The core of the program is your own nurse coach who works with you oneon-one. This close attention gives you the control and help you need to feel your best. Here s how it works: Your nurse coach helps you build a personal plan for better health a plan that is easy to follow and can work for you! You ll talk with your nurse coach (by phone or online) whenever you have a question or could use some advice. Your nurse coach and your doctor will have access to important health information about your condition and things that might help you. You ll form a stronger working partnership with your doctor. (This service does not replace your doctor in any way.) Plus, you ll have additional online resources and tools through the MyActiveHealth SM member portal that can help you stay on top of your health. When you join the program, you ll see benefits right away! Understand your condition and how things you do every day impact your health. Work with your nurse coach to set goals that will help you live healthier and feel better. Learn how to reduce your risk of heart disease, stroke and other serious conditions. You may get a call about Active Disease Management. ActiveHealth Management is tied into your health plan and medical records, so our system can see if you have a chronic condition. Your information is confidential and protected by federal privacy laws. We may give you a call and invite you to participate. Participation is completely voluntary, of course, and there is no cost to you. You can join right now and get started. You may be able to lower your blood pressure or cholesterol, or even get your blood sugar under control. Lose weight or maintain a healthy weight with help from a registered dietician. Work with an exercise specialist to find a routine that fits your lifestyle, and so much more. If you have a chronic health condition (listed on the back of this brochure), then you are eligible for Active Disease Management. When you call the number or go to the web address listed below, you ll be assigned a personal nurse coach right away. Take the first step toward feeling and being the best you can be! The nurse coach works at your own pace and on your terms. Everything is built around you and your needs. Since there s no cost, you have everything to gain and nothing to lose. Help for your health is mobile too! Check out the mobile site, where you can: View your health records Use trackers and tools to look up critical information See your health alerts, and more! Why not give it a try? There is so much to gain by working with a nurse coach. Call , Monday-Friday, 8:00am to 8:00pm, EST and Saturday, 9:00am to 2:00pm, EST. or go to AHM130143_DM_Bro_Master_WC.indd 5-6 5/7/13 10:00 PM

10 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Special attention for a healthy pregnancy and baby Beginning Right Maternity Program H (8/12)

11 Helping you and your baby grow healthy together You get the Beginning Right Maternity management program with your Aetna health benefits and insurance plan. You can use it throughout your pregnancy. And even after your baby is born. Information for a healthier pregnancy There s a lot of information on pregnancy. We ll make it easier by sharing materials to help you have a healthy one. You ll get information on: Prenatal care Preterm labor symptoms What to expect before and after delivery Newborn care and more All program materials are in English and Spanish. Special help for pregnancy risks Some women have health conditions or risk factors that could hurt their pregnancy. If you do, you can work with a nurse case manager to help you lower those risks. If English isn t the language you speak at home, don t worry. We have a translation service. So we can offer help in over 170 languages. If you re eligible, you also get: Two follow-up calls after your delivery A screening for depression Extra support, if needed You can take a pregnancy risk survey. It s on your Aetna Navigator website at Solid support to quit smoking If you aren t smoking wonderful! If you are, here are some wonderful reasons to quit. You ll lower your baby s risk for preterm delivery, low-birth weight and sudden infant death syndrome (SIDS). And you re not in it alone. With the Beginning Right Smoke-Free Moms-to-Be program, you ll get one-on-one nurse support to help you quit smoking for good. Lower your risk for preterm labor Some babies are born much sooner than expected. This can raise the risk for complications. If you re at risk of preterm labor, we ll teach you the signs and symptoms of early labor. You ll also hear about new treatment options. Your online source The more you know, the healthier you both can be. Visit Aetna Women s Health online at to learn about: Reproductive health Menopause Breast and heart health Migraines Pregnancy and baby care Depression and more It s easy to enroll in the Beginning Right program: 1. Call us toll-free at CRADLE-1 ( ), weekdays from 8 a.m. to 7 p.m., ET, or 2. Log in to Aetna Navigator at and look under Health Programs. Health benefits and health insurance plans are offered, underwritten and/or administered by: Aetna Health Inc., Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford CT Each insurer has sole responsibility for its own products. This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Health benefits and health insurance plans contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Policy forms issued in Oklahoma include: HMO/OK COC-5 09/07, HMO/OK GA-3 11/1, HMO OK POS RIDER 8/07, GR-23 AND/OR GR-29/GR-29N Aetna Inc H (8/12)

12 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Informed Health Line Get your health questions answered anytime, anywhere C (2/13)

13 Call our 24-hour nurse line for your health questions When your health question can t wait, you have a resource to turn to the Informed Health Line. With one call, you can: Get information on a wide range of health and wellness topics. Get s from a nurse with videos that are relevant to your question or topic. Make smarter health care decisions. Find out more about a medical test or procedure. Get help preparing for a doctor s visit. It s toll-free. And you can call as many times as you need to at no extra cost. Ways to get health information fast Call a nurse at For speech or hearing impaired, dial 711.* Visit your secure member website at Get health information when and where you need it. Call For speech or hearing impaired, dial 711.* Or log in to Get health information online, too If you like to dig for health information on the web, you ll love this site. You can: Use the symptom checker. Learn about a medical test that s coming up. Research a new medication you re taking and more. Log in to your secure member website at Choose Health Programs, then 24-Hour Nurse Line. *Ask the relay operator to dial and select the option to speak to a nurse. Health insurance plans are offered, underwritten or administered by Aetna Life Insurance Company and its affiliates (Aetna). Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to Aetna Inc C (2/13)

14 Today, medical technology is able to capture detailed diagnostic images, including the functions of the heart, brain and more. This fastgrowing field of radiology, which used to involve mainly X-rays and ultrasounds, now encompasses MRI, CT, PET and other emerging technologies. These services are performed to create snapshots of what is going on inside your body. Because you are an Aetna member, your doctor can order a broad range of diagnostic studies on your behalf. It is important to recognize that these procedures provide visual information and are not medical treatments. They provide diagnostic support when an ailment is suspected, an injury has occurred or to prepare for surgery. 730 Cool Springs Boulevard Suite 800 Franklin, TN medsolutions.com Your Radiology Benefits A Member Guide from Aetna 1. Shrimpton, P.C; Miller, H.C; Lewis, M.A; Dunn, M. Doses from Computed Tomography (CT) examinations in the UK Review 2. Feng YJ et al. Estimated cosmic radiation doses for flight personnel. Space Med Med Eng 15(4):265-9; MedSolutions, Inc.

15 The Prior Authorization Process High-tech radiology, like other medical procedures, requires prior authorization before coverage is provided for the study. The process is simple: Prescribe: Your doctor requests coverage for a particular imaging study (or studies) to assist his or her diagnosis. Submittal: The doctor s office submits the request to Aetna s Radiology Benefits Management provider MedSolutions. Review: MedSolutions uses its clinical expertise in conjunction with national radiology standards to review all the details of the request: Is it the appropriate test, the right timing, the accurate body area, and an appropriate facility for the test? Approval: In the vast majority of cases, the study is approved usually in a few minutes or less. In some cases, a peer-topeer discussion between doctors is necessary to get further clarification on the medical condition before the test is approved. What if an imaging request is denied? n In a small number of cases, an alternate recommendation is indicated during the review process. The reasons for denial include: The physician did not order the most appropriate test A more limited imaging area is sufficient for the condition An alternative course of action is recommended at this time An accurate diagnosis can be made without subjecting the patient to unnecessary exposure to radiation or inconvenient and often uncomfortable testing. What happens after a denial? n If there is a denial, your physician will be phoned by MedSolutions. Your physician can discuss the case with a medical director in order to determine the best course of action. In some cases, your physician will provide additional information to support the request. In other cases, your physician will accept an alternate recommendation designed to provide the same or a better outcome. n There is also an appeal process if you or your physician feels that there are extenuating circumstances that have not been considered. Should I be concerned about long-term radiation exposure? n There is no conclusive evidence of exactly what long-term radiation exposure will do to the human body. It has been widely researched and accepted that radiation exposure accumulates over time. While the benefits of performing a needed test clearly outweigh the risk, the prudent course is to limit radiation exposure to what is medically necessary. n Tests also vary greatly in the radiation dose delivered. A traditional chest X-ray might deliver 10 millirems of exposure while a chest CT might deliver 580 millirems. 1 The difference is that a CT scan is a much more sophisticated diagnostic tool. By comparison, a flight attendant receives about 219 millrems per year on the job from cosmic radiation. 2 n MRIs, on the other hand, do not use radiation at all. Instead, they employ a powerful magnetic field, radio waves and a computer to indicate whether or not there is an injury or disease process present. While X-rays, MR and CT differ in radiation exposure, cost and availability, they each have an appropriate purpose as diagnostic tools. Because you are an Aetna member, your doctor can order a broad range of diagnostic studies on your behalf. About MedSolutions n MedSolutions is a radiology management company that works with health plans to help them achieve appropriate and effective diagnostic imaging procedures for their members. MedSolutions uses a specialized team of physicians and nurses with high-tech radiology expertise to help your physician make diagnostic imaging decisions to meet your needs.

16 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Participating Provider Precertification List Effective November 1, 2014 Reference general precertification information. 1 Applies to: all Aetna plans, except Traditional Choice plans; all Innovation Health SM plans. 1, 2 1. Inpatient confinements Surgical and nonsurgical Skilled nursing facility Rehabilitation facility Inpatient hospice (except Medicare) Maternity and newborn confinements that exceed the standard length of stay (LOS) 3 2. Ambulance Transportation by fixed-wing aircraft (plane) Elective (non-emergency) transportation by ground ambulance or medical van for Medicare Advantage plan members only 3. Autologous chondrocyte implantation, Carticel 4 4. Cochlear device and/or implantation 4 5. Cognitive skills development 4 6. Dental implants 7. Dialysis visits Call or fax applicable request forms to Dorsal column (lumbar) neurostimulators: trial or implantation 4 9. Electric or motorized wheelchairs and scooters 10. Gastrointestinal (GI) tract imaging through capsule endoscopy 4 Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Innovation Health Insurance Company and Innovation Health Plan, Inc. (Innovation Health) are affiliates of Aetna Life Insurance Company (Aetna) and its affiliates. Aetna and its affiliates provide certain management services for Innovation Health E (11/14)

17 11. Home health care related services Private duty nursing, maternity management home care and home uterine activity monitoring All home health care for Medicare Advantage plan members only Effective June 2, 2014, precertification is not required Home hospice for Medicare Part B plan members only Effective June 2, 2014, precertification is not required 12. Hyperbaric oxygen therapy Limb prosthetics 5, 6, Drugs and medical injectables Blood-clotting factors Precertification for outpatient infusion of this drug class is required For the following services, call or fax applicable request forms to NaviNet users, please use the drug authorizations online form located under Services. Actimmune Makena Acthar Gel Multiple sclerosis drugs: Adcetris - Aubagio, Avonex, Betaseron, Copaxone, Extavia, Alpha 1-proteinase inhibitor human Gilenya, Rebif, Tecfidera, Tysabri Antiemetics: - Plegridy TM precertification required effective - Aloxi IV, Anzemet IV and Emend IV November 7, 2014 Benlysta Nucleotide polymerase inhibitors indicated for Hepatitis C Botulinum toxin types A and B (Botox, Dysport, Osteoporosis drugs injectable: incobotulinumtoxin a, Myobloc, Xeomin ) - ibandronate sodium (Boniva ), Forteo, Miacalcin Enzyme replacement drugs: and Prolia - Precertification for outpatient infusion of this drug class - zoledronic acid (Zometa, Reclast ) and pamidronate is also required (Aredia ) (for osteoporosis indications only) Erbitux Pegylated interferon alpha when used for hepatitis C: Erythropoiesis-stimulating agents (ESA), such as - Pegasys, PegIntron, Rebetron, Roferon-A, darbepoetin alpha, epoetin alpha and epoetin beta Intron A, Infergen Gattex Protease inhibitors indicated for Hepatitis C Gazyva - with the exception of Incivek (telaprevir) and Victrelis (boceprevir) Growth hormone Provenge Hereditary angioedema drugs Pulmonary arterial hypertension drugs HER2-targeted receptors Soliris Immunologic agents: Sofosbuvir with ledipasvir precertification required - Actemra, Actemra SC, Amevive, Cimzia, Enbrel, effective October 10, 2014 Humira, Kineret, Orencia, Otezla, Remicade, Rituxan, Simponi, Simponi Aria, Stelara, Xeljanz Synagis - Entyvio precertification required effective July 18, 2014 Vectibix Immunoglobulins: Viscosupplementation: - Any parenteral administration intravenous (IV), - Euflexxa, Gel-One, Hyalgan, Orthovisc, Supartz, subcutaneous (SubQ) and/or intramuscular (IM) Synvisc, Synvisc-One - Precertification for outpatient infusion of this drug class - Monovisc precertification required effective is required July 11, 2014 Infertility medications (injectable) Xgeva Jevtana Xofigo Keytruda precertification required effective Xolair November 7, 2014 Yervoy Krystexxa Zaltrap 15. Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider

18 16. Oncotype DX Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint 18. Osseointegrated implant Osteochondral allograft/knee Proton beam radiotherapy Reconstructive or other procedures that may be considered cosmetic Blepharoplasty/canthoplasty Breast reconstruction/breast enlargement Breast reduction/mammoplasty Cervicoplasty Chemical peels Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Injection of filling material Lipectomy or excess fat removal Sclerotherapy or surgery for varicose veins 22. Referral or use of nonparticipating physician or provider for non-emergent services, unless the member understands and consents to the use of a nonparticipating provider under their out-of-network benefits when available in their plan 23. Spinal procedures 4 Artificial intervertebral disc surgery Cervical, lumbar and thoracic laminectomy/laminotomy procedures Spinal fusion surgery 24. Uvulopalatopharyngoplasty, including laser-assisted procedures Ventricular assist devices Special programs Beginning Right maternity program Including genetic testing, antenatal testing, perinatal consultations and counseling: BRCA genetic testing Cardiac rhythm implantable devices Precertification for all members with plans applicable to this precertification list unless services are emergent: Providers in all states where applicable, except metro New York and northern New Jersey, should contact MedSolutions to request preauthorization. You can reach MedSolutions: - Online at - By phone at between 7 a.m. and 8 p.m. ET - By fax at Monday through Friday during normal business hours or as required by federal or state regulations Providers in metro New York and northern New Jersey should contact CareCore National to request preauthorization. You can reach CareCore National: - Online at - By phone at for metro New York or for northern New Jersey

19 Chiropractic precertification HMO-based plan members only - AZ through American Specialty Health (ASH) HMO-based plan and Group Medicare members only - CA through American Specialty Health (ASH) HMO-based, Aetna Health Network Option SM, Aetna Health Network Only SM and Medicare Advantage plan members only - Metro and upstate New York through American Chiropractic Network (OptumHealth) NJ through Triad For all members (with commercial and Medicare Advantage plans applicable to this precertification list): - CT; DC; DE; GA; Chicago, IL; MA; PA; and VA through American Specialty Health (ASH) For all members (enrolled in commercial, Medicare Advantage and international plans applicable to this precertification list) when the provider is contracted with OptumHealth/Aetna: - NC and SC through OptumHealth Infertility program Mental health or substance abuse services precertification See the member s ID card National Medical Excellence Program for all major organ transplant evaluations and transplants including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after high-dose chemotherapy Outpatient physical therapy (PT) and occupational therapy (OT) precertification Through OrthoNet Metro New York and northern New Jersey For HMO-based and Medicare Advantage plan members only - CT For all members with plans applicable to this precertification list Through OptumHealth (ONLY OptumHealth/Aetna-contracted providers should call this number for questions and service requests) - DC, GA, NC, SC, VA For all members with plans applicable to this precertification list Pre-implantation genetic testing Pediatric Congenital Heart Surgery Program See the member s ID card to contact the precertification unit Polysomnography (attended sleep studies) Precertification for all members with plans applicable to this precertification list when performed in any place of service except inpatient, emergency room and observation bed status Providers in all states where applicable, except metro New York and northern New Jersey, should contact MedSolutions to request preauthorization. You can reach MedSolutions: - Online at - By phone at between 7 a.m. and 8 p.m. ET - By fax at Monday through Friday during normal business hours or as required by federal or state regulations Providers in metro New York and northern New Jersey should contact CareCore National to request preauthorization. You can reach CareCore National: - Online at - By phone at

20 Radiation oncology Precertification for all members with plans applicable to this precertification list when performed in any place of service except inpatient, emergency room and observation bed status Metro New York and northern New Jersey Radiation oncology precertification through CareCore National for HMO-based and Medicare Advantage plan members only. You can reach CareCore National: - By phone at for northern New Jersey members - By phone at for metro New York members Radiology imaging Precertification for all members with plans applicable to this precertification list when performed in any place of service except inpatient, emergency room and observation bed status Through regional specific vendor (MedSolutions or CareCore National) where applicable for computed tomographic (CT) studies, coronary CT angiography, MRI/MRA, nuclear cardiology, PET scans, diagnostic left and right heart catheterizations and echo stress tests Transthoracic echocardiogram Precertification for all members with plans applicable to this precertification list when performed in any place of service except inpatient, emergency room and observation bed status Providers in metro New York and northern New Jersey should contact CareCore National to request preauthorization. You can reach CareCore National: - Online at - By phone at for metro New York members - By phone at for northern New Jersey members

21 General information 1. Precertification and notification are the processes of collecting information before elective inpatient admissions and/or selected ambulatory procedures and services take place. a. Requests for precertification and notification must be received before rendering services. b. Failure to contact the member s health plan (the health plan ) for precertification will relieve the health plan or employers and members from any financial liability for the applicable service(s), if those services are rendered. c. This material is provided for informational purposes only. It s not intended to direct treatment decisions. d. Precertification is the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company s clinical criteria for coverage. e. The level of review of individual items on this precertification list may vary from time to time at our discretion. The lack of a denial for a particular service or supply should not be interpreted as our approval for any subsequent service. f. In Texas, the reference to precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company s clinical criteria for coverage. Precertification does not mean a reliable representation of payment for care or services to fully insured HMO and PPO members as defined by Texas law. g. Electronic submission of precertification requests and inquiries is preferred. If you require assistance with precertification, please call our Aetna Voice Advantage line using the appropriate phone number indicated on the member s ID card and select the precertification option. h. Visit Clinical Policy Bulletins and our online provider directory. i. Provided that there are no changes to member eligibility and plan coverage for the procedure/service requested, precertification approvals are valid for six months in all states unless otherwise indicated at the time of precertification. j. Services not included on the precertification list are subject to the coverage terms of the member s plan. 2. Not all plans are offered in all service areas and not all plans include all services listed. For example, precertification programs don t apply to fully insured members in Indiana. Innovation Health Insurance Company and Innovation Health Plan, Inc. (Innovation Health) are affiliates of Aetna Life Insurance Company (Aetna) and its affiliates. Aetna and its affiliates provide certain management services for Innovation Health. Precertification is required when Aetna or Innovation Health is secondary payer. 3. Precertification is required for maternity and newborn confinements that exceed the standard LOS. Standard LOS for vaginal deliveries is a total of three days or less; standard LOS for Cesarean section is a total of five days or less. 4. All services deemed never effective are excluded from coverage. Aetna defines a service as never effective when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through for more information. Select Claims, CPT/HCPCS Coding Tool, Clinical Policy Code Lookup. 5. For precertification of oral medications not indicated on this list, contact Aetna Pharmacy Management at Call for information on injectable medications not listed. 7. For drugs administered orally, by injection or infusion: a. For medical injectables and drugs requiring precertification, call or fax applicable request forms to b. NaviNet users, please use the drug authorizations online form located under Services. c. Newly U.S. Food and Drug Administration (FDA)-approved drugs may be subject to precertification review. d. Fully insured Texas and Louisiana members continue to receive coverage for drugs added to the precertification list in accordance with their current plan benefit design until their next plan renewal date. e. Fully insured California HMO members and fully insured Connecticut PPO members receiving coverage for drugs added to the precertification list continue to have coverage. Drug coverage continues for these California members as long as the drug is appropriately prescribed and considered safe and effective treatment for the medical condition. Drug coverage continues for these Connecticut members as long as the drug is medically necessary and more medically beneficial than other covered drugs Aetna Inc E (11/14)

22 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Behavioral Health Precertification List Services requiring precertification*/ authorization Behavioral health services requiring precertification/authorization This applies only to services covered under the member s benefits plan. Inpatient admissions Residential Treatment Center (RTC) admissions Partial Hospitalization Programs (PHPs) Intensive Outpatient Programs (IOPs) Psychological testing Neuropsychological testing Outpatient Electroconvulsive Therapy (ECT) Biofeedback Amytal interview Psychiatric home care services Outpatient detoxification Applied Behavior Analysis (ABA) How to request precertification/authorization To get precertification/authorization for mental health, substance abuse or behavioral health services, submit an electronic precertification request on our secure provider website on NaviNet at Register for the site at Or you can choose any other website that allows precertification requests from our list at You can also inquire electronically on previously submitted requests. Open Choice and Traditional Choice plans require precertification for inpatient admissions and residential treatment, although they may not have precertification requirements for additional outpatient procedures listed here. Exceptions to this policy This policy applies to all Aetna plans with the exception of: Behavioral health benefits plans that we administer, but do not manage Self-funded plans with plan sponsors who have expressly purchased precertification requirements * The term precertification means the utilization review process to determine whether the requested service or procedure meets the company s clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured health maintenance organization (HMO) and preferred provider organization (PPO) members I (3/14)

23 For more information about precertification, go to Applies to*: Aetna Choice POS, Aetna Choice POS II, Aetna Medicare SM Plan (PPO), Aetna Medicare SM Plan (HMO), all Aetna HealthFund products, Aetna Health Network Only SM, Aetna Health Network Option SM, Aetna Open Access Elect Choice, Aetna Open Access HMO, Aetna Open Access Managed Choice, Open Access Aetna Select SM, Elect Choice, HMO, Managed Choice POS, Traditional Choice, Open Choice, Quality Point-of-Service (QPOS ) benefits plans, Choose and Save SM, Savings Plus, Aetna Select SM benefits plans and all products that may include the Aexcel ** networks and include the designation Aexcel or Aexcel Plus. * Not all plans are offered in all service areas. Aetna HealthFund PPO, Aetna HealthFund Managed Choice, Aexcel, Aetna Choice POS, Aetna Choice POS II, Aetna Medicare plans, Aetna Open Access Managed Choice and QPOS benefits plans may include the option for members to elect to go outside the network and receive reduced benefits. ** Aexcel is not available with HMO plans. Aexcel designation is only a guide to choosing a physician. Members should confer with their existing physicians before making a decision. Designations have the risk of error and should not be the sole basis for selecting a doctor. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies (Aetna). Aetna Behavioral Health refers to an internal business unit of Aetna. This material is for informational purposes only and is not medical advice. Health benefits and health insurance plans contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a therapist, physician or other health care professional. Contact a health care professional with any questions or concerns about specific health care needs. Participating providers are independent contractors and neither agents nor employees of Aetna. Information is believed to be accurate as of the production date; however, it is subject to change Aetna Inc I (3/14)

24 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Preventive care covered with no cost sharing Get checkups, screenings, vaccines, prenatal care, contraceptives and more with no out-of-pocket costs E (10/14)

25 Good news your health benefits and insurance plan covers the services listed here with no cost share * as part of preventive care. * Employers with grandfathered plans may choose not to cover some of these preventive services, or to include cost share (deductible, copay or coinsurance) for preventive care services. Certain religious employers and organizations may choose not to cover contraceptive services as part of the group health coverage. Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT Each insurer has sole financial responsibility for its own products.

26 This includes routine screenings and checkups. It also includes counseling you get to prevent illness, disease or other health problems. Many of these services are covered as part of physical exams. These include regular checkups and routine gynecological and well-child exams. You won t have to pay out of pocket for these preventive visits, when provided in network. But these services are generally not preventive if you get them as part of a visit to diagnose, monitor or treat an illness or injury. Then copays, coinsurance and deductibles may apply. Aetna follows the recommendations of national medical societies about how often children, men and women need these services. Be sure to talk with your doctor about which services are right for your age, gender and health status. Covered preventive services for adults generally include: Screenings for: Abdominal aortic aneurysm (one-time screening for men of specified ages who have ever smoked) Alcohol misuse Blood pressure Cholesterol (for adults of certain ages or at higher risk) Colorectal cancer (for adults over age 50) Depression Type 2 diabetes (for adults with high blood pressure) Human immunodeficiency virus (HIV) Obesity Tobacco use Lung cancer (for adults ages 55 and over with a history of smoking), effective on renewal on or after January 1, 2015 Syphilis (for all adults at higher risk) Medication and supplements: Aspirin for men and women ages 45 and older with certain cardiovascular risk factors Vitamin D supplements for adults ages 65 and older with certain conditions Tobacco-cessation medications approved by the U.S. Food and Drug Administration (FDA), including over-the-counter medications when prescribed by a health care provider and filled at a participating pharmacy Counseling for: Alcohol misuse Diet (for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease) Obesity Sexually transmitted infection (STI) prevention (for adults at higher risk) Tobacco use (including programs to help you stop using tobacco) Immunizations: Doses, recommended ages and recommended populations vary. Diphtheria, pertussis, tetanus (DPT) Hepatitis A and B Herpes zoster Human papillomavirus (HPV) Influenza Measles, mumps, rubella (MMR) Meningococcal (meningitis) Pneumococcal (pneumonia) Varicella (chickenpox)

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