PLAN FEATURES	IN-NETWORK	
Benefit limitations - Some service or supplies have limits on them per year. There might be a maximum number of visits or days, or a dollar limit per year. In such cases, the benefit year begins on January 1 (unless otherwise noted). Refer to your plan documents to learn more.	
Deductible (per calendar year)	$2,500 per Individual	
	$5,000 per Family	
You must first meet the deductible before the plan begins paying benefits, unless otherwise noted.	
The amount you pay (cost sharing) for some medical services does not count toward your deductible. Prescription drug costs count toward the deductible. Refer to your plan documents for details.	
Once you meet the family deductible, then all family members have met it for the rest of the year. There is no individual deductible for members of a family.	
Member coinsurance	You pay 30%	
Applies to all expenses except as noted.	
Out-of-pocket limit (per calendar year)	$5,000 per Individual	
	$7,500 per Family	
Some of your cost sharing may not count toward the out-of-pocket limit.	
Your pharmacy expenses count toward your out-of-pocket limit.	
In-network expenses include coinsurance/copays and deductibles.	
Once you meet the family out-of-pocket limit, then all family members have met it for the rest of the year. There is no individual out-of-pocket limit for members of a family.	
Lifetime maximum	
Unlimited except where otherwise indicated.	
Primary care physician selection	Encouraged	
Referral requirement	Not required	
Telehealth consultations - You can access covered services for telehealth visits from different kinds of providers in your plan. Log on to Aetna.com to see a list of telehealth providers. You'll also find more about your options, including cost share amounts.	
PREVENTIVE CARE	IN-NETWORK	
Routine adult physical exams/ immunizations	Covered 100%; no deductible	
1 exam every 12 months until age 65, then 1 exam every 12 months age 65 and older	
Routine well child exams/immunizations	Covered 100%; no deductible	
• 7 exams in the first 12 months
• 3 exams from age 13 to 24 months
• 3 exams from age 25 to 36 months
• 1 exam every 12 months thereafter until age 22	
Routine gynecological care exams	Covered 100%; no deductible	
1 exam and pap smear per year, includes related fees.	
Virtual primary care (VPC) preventive care consultations	Covered 100%; no deductible	
Includes screening and counseling services for members age 18 and older	
Routine mammogram	Covered 100%; no deductible	
Recommended: One per year for members age 40 and over	
Women's health	Covered 100%; no deductible	
Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling.	
Also includes: contraceptive methods (ACA mandated contraceptives, including contraceptives and devices you can't get at a pharmacy), sterilization procedures (including tubal ligation), patient education and counseling. Limits may apply.	
Pre-natal maternity	Covered 100%; no deductible	
Routine digital rectal exam	Covered 100%; no deductible	
Recommended: For members age 40 and over	
Prostate-specific antigen test	Covered 100%; no deductible	
Recommended: For members age 40 and over	
Colorectal cancer screening	Covered 100%; no deductible	
Recommended: For members age 45 and over	
Routine eye exams	Covered 100%; no deductible	
1 routine exam per 24 months.	
Routine hearing screening	Covered 100%; no deductible	
PHYSICIAN SERVICES	IN-NETWORK	
Office visits to primary care physician (PCP)	30%; after deductible	
Includes services of an internist, general physician, family practitioner or pediatrician.	
Virtual primary care (VPC) consultations	Covered 100%; after deductible	
Includes basic medical service consultations through a VPC vendor for members age 18 and older; refer to Aetna.com for VPC vendor information.	
Specialist office visits	30%; after deductible	
Hearing exams	Covered 100%; no deductible	
1 routine exam per 24 months.	
Walk-in clinics	30%; after deductible	
	Designated Walk-in clinics	
	Covered 100%; after deductible	
Walk-in clinics are free-standing health care facilities. Sometimes they may be within a pharmacy, drug store, supermarket, or other retail store. They offer some limited medical care and services.	
Not walk-in clinics: Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers, and physician offices.	
Allergy testing	Your cost sharing amount depends on the type of service and where you receive it.	
Allergy injections	Your cost sharing amount depends on the type of service and where you receive it.	
DIAGNOSTIC PROCEDURES	IN-NETWORK	
Diagnostic X-ray (Other than complex imaging services)	30%; after deductible	
When your physician performs and bills for this service at their office, you pay your office visit cost share amount.	
Diagnostic laboratory	30%; after deductible	
When your physician performs and bills for this service at their office, you pay your office visit cost share amount.	
Diagnostic complex imaging	30%; after deductible	
When your physician performs and bills for this service at their office, you pay your office visit cost share amount.	
EMERGENCY MEDICAL CARE	IN-NETWORK	
Urgent care provider	30%; after deductible	
Non-urgent use of urgent care provider	Not Covered	
Emergency room	30%; after deductible	
Non-emergency care in an emergency room	Not Covered	
Emergency use of ambulance	30%; after deductible	
Non-emergency use of ambulance	Not Covered	
HOSPITAL CARE	IN-NETWORK	
Inpatient coverage	30%; after deductible	
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Inpatient maternity coverage (includes delivery and postpartum care)	30%; after deductible	
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Outpatient hospital	30%; after deductible	
When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.	
Outpatient surgery - hospital	30%; after deductible	
When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.	
Outpatient surgery - freestanding facility	30%; after deductible	
When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.	
MENTAL HEALTH SERVICES	IN-NETWORK	
Inpatient	30%; after deductible	
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Mental health office visits	30%; after deductible	
Other mental health services	30%; after deductible	
When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.	
SUBSTANCE ABUSE 	IN-NETWORK	
Inpatient	30%; after deductible	
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Residential treatment facility	30%; after deductible	
When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Substance abuse office visits	30%; after deductible	
Other substance abuse services	30%; after deductible	
When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.	
THERAPY SERVICES	IN-NETWORK	
Spinal manipulation therapy	30%; after deductible	
Limited to 20 visits per year	
Outpatient short-term rehabilitation	30%; after deductible	
Limited to 30 visits per year	
Includes physical, occupational, and speech therapies.	
Habilitative physical therapy	30%; after deductible	
Habilitative occupational therapy	30%; after deductible	
Habilitative speech therapy	30%; after deductible	
Autism related physical therapy	30%; after deductible	
Autism related occupational therapy	30%; after deductible	
Autism related speech therapy	30%; after deductible	
Autism related behavioral therapy	30%; after deductible	
These benefits are combined with outpatient mental health visits	
Autism related applied behavior analysis	30%; after deductible	
Your benefits for these services are the same as any other outpatient mental health other services benefit	
OTHER SERVICES	IN-NETWORK	
Skilled nursing facility	30%; after deductible	
Limited to 60 days per year	
When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Home health care	30%; after deductible	
Limited to 60 visits per year	
Home health care services include private duty nursing	
Limited to three visits per day by staff from a home health care agency. One visit equals a period of four hours or less.	
Hospice care - inpatient	30%; after deductible	
When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.	
Hospice care - outpatient	30%; after deductible	
When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.	
Private duty nursing	Covered as part of home health care	
We count each period of up to 8 hours as one private duty nursing shift.	
Durable medical equipment	30%; after deductible	
Diabetic supplies -- (if not covered under the prescription drug benefit)	Covered same as any other medical expense.	
	You pay your prescription drug cost sharing amount if you have prescription drug coverage. If not, you pay your PCP visit cost sharing amount.	
Infusion therapy - home/office	30%; after deductible	
Infusion therapy - outpatient hospital/freestanding facility	30%; after deductible	
Gene-based, Cellular, and other Innovative Therapies (GCIT™)	Your cost sharing amount depends on the type of service and where you receive it.	
	30%: after deductible for gene therapy drugs, if applicable	
	In-network coverage is provided at GCIT™ designated facilities only.	
Hearing aids	Not Covered	
Transplants	30%; after deductible	
	In-network coverage is only available at Institutes of Excellence (IOE) contracted facility.	
Bariatric surgery	Not Covered	
Acupuncture	30%; after deductible	
Limited to 10 visits per year	
FAMILY PLANNING	IN-NETWORK	
Infertility treatment	Your cost sharing amount depends on the type of service and where you receive it.	
You have coverage for the diagnosis and treatment of the underlying cause of infertility.	
Comprehensive infertility services	30%; after deductible	
Coverage includes artificial insemination and ovulation induction limited to six courses of treatment per member lifetime.  Lifetime maximum applies to all procedures covered by any of our plans except where prohibited by law.	
Advanced Reproductive Technology (ART)	30%; after deductible	
Limited to 3 courses of treatment per member's lifetime. Maximum applies to all procedures covered by any of our plans except where prohibited by law.	
ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery.	
Vasectomy	Your cost sharing amount depends on the type of service and where you receive it.	
Tubal ligation	Covered 100%; no deductible	
PHARMACY	IN-NETWORK	
The full cost of the drug is applied to the deductible before any benefits are considered for payment under the pharmacy plan.	
Pharmacy plan type	Advanced Control Plan - Aetna	
Prescription drug deductible	Prescription drug expenses apply to your medical deductible.	
Preventive medications - We waive the deductible for certain preventive medications. For a full list of these drugs, go to your secure member site or ask your employer.	
Prescription drug out-of-pocket limit	Prescription drug expenses apply to your medical out-of-pocket limit.	
Preferred generic drugs	
Retail	$10 copay	
Mail order	$20 copay	
Preferred brand-name drugs	
Retail	$30 copay	
Mail order	$60 copay	
Non-preferred generic and brand-name drugs	
Retail	$60 copay	
Mail order	$120 copay	
Pharmacy day supply and requirements	
Retail	You can get up to a 30-day supply from Aetna National Network	
Mandatory maintenance choice	Maintenance drugs are prescriptions commonly used to treat conditions that require regular, daily use of medicines.	
	If you take a maintenance drug, you can get two retail fills.	
	Then you must fill a 31-90-day supply of the maintenance drug at CVS Caremark® Mail Service Pharmacy or a CVS Pharmacy®.1	
	If you do not, you will need to pay 100% of the drug cost.	
Opt Out	You must notify us if you want to continue to fill the medicine at a network retail pharmacy. Just call the number on the member ID card.	
Specialty	You can get up to a 30-day supply of specialty drugs	
	You must fill all specialty drugs through our preferred specialty pharmacy network.	
	Advanced Control Formulary AFA List	
Your prescription drug plan also includes:	
• Diabetic supplies	
• Sexual dysfunction drugs, including daily dose, additional 6 tablets a month for erectile dysfunction	
• A limited list of over-the-counter medications when filled with a prescription	
The following are covered 100% in-network:	
• Oral chemotherapy drugs	
• Seasonal vaccinations	
• Preventive vaccinations	
• Affordable Care Act (ACA) eligible preventive medications and contraceptives	
Refer to Aetna.com for a complete list of eligible prescription drugs.	
Precertification requirements	
Some covered prescription drugs need approval from us before we will cover the drug.	
Some covered prescription drugs require step therapy before we cover them. With step therapy, you must first try one or more drugs before we will pay for drugs that require step therapy.	
To get the most up-to-date precertification requirements and a list of drugs that require step therapy, see your plan documents or go online to your member website.	
Choose generics - Sometimes you or your provider may ask for a brand-name prescription drug when a generic is available. If so, you will pay the brand-name copay plus the difference between the generic price and the brand-name price.	
The cost difference that you pay will not apply to your deductible or out-of-pocket limit.	
GENERAL PROVISIONS	
Dependents who are eligible to be on your plan	Spouse, children from birth to age 26. Student status of children does not matter.	

Plans are provided by: Aetna Health Inc. While this material is believed to be accurate as of the production date, it is subject to change.	

Health benefits and 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 our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services.	
The following is a list of services and supplies that are generally not covered.  However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.	
• All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents. 
• Cosmetic surgery, including breast reduction.
• Custodial care.
• Dental care and dental X-rays.
• Donor egg retrieval
• Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial. 
• Hearing aids
• Home births
• Immunizations for travel or work, except where medically necessary or indicated.
• Implantable drugs and certain injectable drugs including injectable infertility drugs.
• Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents.
• Long-term rehabilitation therapy.
• Non-medically necessary services or supplies.
• Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over-the-counter medications (except as provided in a hospital) and supplies.
• Radial keratotomy or related procedures.
• Reversal of sterilization.
• Services for the treatment of sexual dysfunction/enhancement, including therapy, supplies or counseling or prescription drugs.
• Special duty nursing.
• Therapy or rehabilitation other than those listed as covered.
• Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions.	

In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.	

Translation of this material into another language may be available.  Please call Member Services at the number on the back of your ID card.	

Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-982-3862.	

Plan features and availability may vary by location and group size.	

For more information about Aetna plans, refer to www.aetna.com.	
Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family.	

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