Prudential Financial: Aetna HMO (Aetna Select network) Effective Date:

Transcription

1 Prudential Financial: Aetna HMO (Aetna Select network) Effective Date: PROGRAM FEATURES Deductible (per calendar year) PROGRAM DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY None None Individual Family Out-of-Pocket Maximum $1,200 Individual Applies to all expenses unless otherwise stated. $2,400 Family Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Copays, behavioral health and prescription drug charges do not apply toward the out-of-pocket maximum. Lifetime Maximum Primary Care Physician Selection Unlimited except where otherwise indicated. Required Certification Requirements Certification for certain types of Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required. Precertification for certain procedures/treatments is required Referral Requirement Required (except for annual OB/GYN exams and mammograms) PREVENTIVE CARE Routine Physical Exam: frequency limits may apply. Includes Adult & Child Tuberculosis testing and Includes work & travel immunizations. (Covers basic ear and eye screenings performed by a physician as part of a routine exam). Routine Adult Physical Exams/ Immunizations: (also applies to routine exam-related x-ray & lab) Routine Well Child Exams/Immunizations: Recommend: 7 exams in the first 12 months of life, 2 exams in the 13th-24th months of life; 1 exam per 12 months thereafter to age 18.

2 Routine Gynecological Care Exams: 1 routine Gynecological Exam & PAP Test per year. Routine Mammograms: For covered females age 40 and over. Routine Digital Rectal Exam / Prostatespecific Antigen Test For covered males age 40 and over. PHYSICIAN SERVICES Office Visits to PCP: Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits: Office Visits for Surgery: Maternity OB Visits: Includes pre-natal care, delivery and post-natal care up to negotiated rate Allergy Testing & treatment: Allergy Injections: for injections by any provider, whenever a separate office visit is not charged DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-ray: Diagnostic X-ray for Complex Imaging Services: High Tech radiology precertification required EMERGENCY MEDICAL CARE Urgent Care Provider: Emergency Room: Copay waived if admitted Non-Emergency care in an Emergency Room: Hospital/Birthing Center at after $200 hospital copay per admission after $100 copay 50% Coinsurance; No Copay

3 Ambulance: for emergency transport and for medically necessary transport (facility to facility) HOSPITAL CARE Inpatient Coverage: Copay waived if readmitted for same or related cause within 10 days of discharge. Also waived for all newborns during 1st 31 days of life Outpatient Surgery: Outpatient Hospital Expenses: MENTAL Nervous and Alcohol/Drug Abuse Service: Inpatient & Outpatient: Administered by CIGNA Behavioral Health OTHER SERVICES Convalescent Facility/Skilled Nursing Facility: Limited to 100 days per calendar year. Home Health Care: unlimited visits Hospice: Inpatient/Outpatient: Entry requirements from 6 to 12 months terminal diagnosis. No lifetime maximum. Private Duty Nursing: included under Home Health Care Outpatient Short-Term Rehabilitation: Includes speech, physical, and occupational therapy. (Speech therapy covers only restorative services. Excludes developmental therapy/training and early intervention services.) Spinal Manipulation Therapy: 60 visits calendar year maximum after $200 copay per confinement Included under Home Health Care

4 Acupuncture: Covered in lieu of anesthesia only. Excludes acupuncture for pain therapy/management Mouth, Jaw, and Teeth: Limited to treatment for accidental injury of sound, natural teeth sustained while covered under the program or for surgical removal of a tumor. TMJ: Limited benefit provided on a case by case basis. (Excludes appliances and orthodontic treatment.) Bariatric Surgery: must be reviewed for medical necessity Durable Medical Equipment: Excludes wigs Diabetic Supplies: Covers only related expenses for glucose monitors, external infusion pumps and self management programs. (Excludes self-injectables, and diabetic outpatient drugs, needles, syringes or OTC supplies) RX covered by Medco Health Prescription Drugs: Non-self injectables, drugs provided during an inpatient stay or administered in a provider's office (All prescription drugs are handled by Medco Health. Medco Health covers infertility drugs, self-injectables, and diabetic outpatient drugs, needles, and syringes.) Contraceptive drugs and devices not obtainable at a pharmacy (includes coverage for contraceptive visits) after $200 hospital copay per admission for inpatient facility after $200 hospital copay per admission for inpatient facility

5 Transplants: Coordinated by Patient Management under the National Medical Excellence Program; requires preauthorization. FAMILY PLANNING Infertility Treatment: Includes diagnosis & treatment of underlining medical condition. Applies to artificial insemination, ovulation induction, and advanced reproductive technologies. Voluntary Sterilization: Including tubal ligation and vasectomy. PHARMACY RX covered by Medco Health GENERAL PROVISIONS Dependents Eligibility: $20,000 lifetime maximum (Infertility drugs are covered by Medco Health and limited to $6,000 lifetime maximum) Spouse or Domestic Partner or 1 Qualified Adult Sponsored Dependent; Unmarried dependent children under age 19; Unmarried dependent children between the ages of 19 and 24 who are attending school on a full-time basis; Unmarried dependent children age 19 or older who are incapable of sustaining employment due to a mental or physical disability Pre-existing Conditions Rule: Does not apply This program does not cover all health care expenses and includes exclusions and limitations. Members should refer to their program documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your program documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. These items include, but are not limited to: Charges for services that do not require the technical skills of a medical, a mental health or a dental professional; Charges for services furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her family, any health care provider or any health care facility; Charges for transportation services other than Medically Necessary ambulance services; Charges for services furnished solely because the person is an Inpatient on any day on which the person s disease or injury could safely and adequately be diagnosed or treated while not confined; Charges for services furnished solely because of the setting if the service or supply could safely and adequately be furnished in a physician s or a dentist's office or other less costly setting;

6 Charges in connection with any injury sustained in the course of (or arising as a result of) any work for wage or profit, whether or not for Prudential; or due to any disease covered by any Workers Compensation law, occupational disease law or similar law with respect to such work; Charges furnished by or for any government unless payment of the charge is required by law; Charges for services or supplies that are provided by any law or governmental program (except for a state program under Medicaid or similar law that is intended to pay benefits in excess of private insurance) under which the patient is or could be covered; Charges for services and supplies not necessary, as determined by the medical carrier, for the diagnosis, care or treatment of the disease or injury involved. This applies even if the services are prescribed, recommended or approved by the attending physician or dentist; Charges for experimental or investigational services or supplies as determined by the carrier based on commonly accepted medical guidelines; Charges for education or special education or job training whether or not given in a facility that also provides medical or psychiatric treatment; Charges for blood or blood plasma that is replaced by or for the patient except for autologous donation in anticipation of scheduled services where in the health plan medical director s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery; Charges for dental services including temporomandibular joints disorders (TMJ), unless the charge is for: - The treatment or removal of a tumor; or - The treatment of natural teeth due to accidental injury within the 12-month period following the accident and the charges are for a doctor s services, x-rays or exams; Charges for care or treatment to the teeth, gums or supporting structures such as, but not limited to, periodontal treatment, endodontic services, extractions, implants or any treatment to improve the ability to chew or speak; Charges for routine foot care; Eye care charges to determine the need for glasses or corrective vision (eyeglasses and contact lenses are also excluded, except for the first pair of contact lenses or eyeglasses for treatment of keratoconus or post-cataract surgery); Charges for or related to any eye surgery mainly to correct refractive errors; Charges for cosmetic or reconstructive surgery, unless the charges are for: - Corrective treatment for an accidental injury (surgery must be performed in the calendar year of the accident which causes the injury or in the next calendar year); - Surgery to treat a condition, including a birth defect, that impairs the function of a body organ; or - Surgery to reconstruct a breast after a mastectomy performed to treat a disease; Hearing exams and hearing aids; Custodial Care, which is non-skilled, personal care provided to help a person in the activities of daily living, such as bathing, dressing, eating, transferring (for example, from a bed to a chair) and toileting. It may also include care that most people do for themselves such as food preparation, diabetes monitoring and/or taking medications which can usually be self administered; Maintenance care, which is care that serves to prevent an existing condition from getting worse rather than to actively treat the condition; Orthopedic footwear, unless determined to be Medically Necessary; Footwear to accommodate a diabetic condition, unless determined to be Medically Necessary;

7 Comfort and convenience items and services including, but not limited to, such items as TVs, telephones, first-aid kits, exercise equipment, air conditioners, humidifiers, saunas and hot tubs; Charges for wigs or other hair replacement supplies; Charges for services or supplies provided by Prudential or by a close relative; Charges for which the covered person is not legally required to pay; Charges for medical transportation except for emergency transportation to the nearest facility equipped to render appropriate care; Charges for the reversal of sterilization; Charges for sex change operations or to treat any gender identity disorders; Charges for therapy, supplies or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis; Marriage, family, child, career, social adjustment, pastoral or financial counseling; Services, treatment, education testing or training related to learning disabilities or developmental delays; Services or supplies furnished by an provider that are in excess of that provider s negotiated charge for the service or supply. This exclusion will not apply to any service or supply for which a benefit is provided under Medicare before the benefits of this Program are paid; The following services are excluded from coverage unless Medically Necessary: macromastia or gynecomastia surgeries, surgical treatment of varicose veins, abdominoplasty, panniculectomy, redundant skin surgery, removal of skin tags, acupressure, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy, and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions; Charges for consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to, bandages and other disposable medical supplies, skin preparations and test strips, except when specified as covered; Charges for care furnished mainly to provide a surrounding free from exposure that can worsen the person s disease or injury; Structural modifications of a personal residence to accommodate a disability; Charges for services of a resident physician or intern rendered in that capacity; Charges for performance, athletic performance or lifestyle enhancement drugs or supplies; Charges for acupuncture therapy. Not excluded is acupuncture when it is performed by a physician or licensed practitioner as a form of anesthesia in connection with surgery that is covered under this Program; Massage therapy; and Membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs. Charges for Prescription Drugs other than those administered in a hospital are not covered under the Medical Program. Such charges are instead covered under the Employee Prescription Drug Program administered by Medco. This list is not all-inclusive.

8 Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the program selected, new prescription drugs not yet reviewed by our medication review committee are either available under programs with an open formulary or excluded from coverage unless a medical exception is obtained under programs that use a closed formulary. This description is not a substitute for the official Plan Documents, which govern the operation of the benefits described. All terms and conditions of these Plans, including your eligibility and any benefits, will be determined pursuant to and are governed by the provisions of the applicable Plan Documents. If there is any discrepancy between the information in this description or in any other materials relating to the benefits described and the actual Plan Documents, or if there is a conflict between information discussed by anyone acting on Prudential s behalf and the actual Plan Documents, the Plan Documents, as interpreted by the Plan Administrator in its sole discretion will always govern. Prudential may, in its sole discretion, modify, amend, suspend or terminate any and all of the policies, programs, Plans and benefits, including those described, in whole or in part, at any time, without notice to or consent of any participant, Employee, or former Employee to the extent permissible under applicable law. For detailed information on any Plan or program, see your applicable Summary Plan Description (SPD), including any applicable Summaries of Material Modifications (SMMs) of the SPDs.