HomeMy WebLinkAboutContract 45773 (2)C1T� SECR�T� � ,.
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AETNA LIFE INSLJRANCE COMPANY
2013 MEDICARE ADVANTAGE PPO
GROUP AGR�EMENT COVER SHEET
Contract Holder:
Contract Holdei• Number:
PPO Plan:
Effective Date:
Term of Group Agreement:
Premium Due Dates:
City Of Fort Worth
411868
031
TX01
MA 100 ESA PPO Benefits Package
with Medicare Prescription Drug benefits
12:01 a.m. on January 1, 2013
The Initial Term shall be: From January 1, 2013
tlu•ough December 31, 2013
Thereafter, Subsequent Terms shall be: From
January 1 st tlu•ough December 31 st
The Group Agreement Effective Date and the 1 st
day of each succeeding calendar month.
Plan Premium Rates: Please refer to the rate/financial e�ibit and/or final
renewal communication (and any amendments
made thereto) issued by Aetna in connection with
this Group Agreement and attached hereto as
Exhibit B("Rate Documents") for applicable rates.
Right to Audit: Aetna agrees that Contract Holder shall, until the
expiration ofone (1) year after final payment under
this agreement, have access to and the right to
examine any directly pertinent books, documents,
papers, and records regarding Contract Holder's
premium, participant census data, and billing under
this Agreement. Aetna agi•ees that Contract Holder�
shall have access during normal working hours to
all necessat•y Aetna facilities and shall be pi•ovided
adequate and appi•opriate woi•Icspace in order to
conduct audits in compliance with this provision.
Contc•act Holder shall give Aetna i•easonable
advance notice of intended audits.
ME PPO GA (Y2013)
OFFICIAL RECORD
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Agreement(s) attached hei•eto on behalf of Aetna and Contract Holdei•.
The signatures below are evidence of Aetna's and Contract Holder's acceptance of the Contract
Holder's Group Application on the terms hereof and constitutes execution of the Group
Agreement(s) attached hereto on behalf of Aetna and Contract Holder.
Signed this _��' � day of
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AETNA LIFE INSiJRANCE COMPANY
By: •
Gr ry S. Martino
Vice President
CONTRACT HOLDER:
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ME PPO GA (Y2013)
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1.5 "Covered Benefits" is a general term we use to mean all of the health care services and
supplies, including Medicare prescription drug benefits, that are covered by Our Plan,
subject to all of the terms and conditions of the EOC and this Group Agreement.
1.6 "EOC" means the Evidence of Coverage, which is a document outlining coverage for
Members under the Plan, that is issued pursuant to this Group Agreement, and includes
the Schedule of Copayments and any riders or amendtnents.
1.7 "Grace Period" is defined in the Premiums and Fees section below.
1.8 "Group Agreement" means the Contract Holder's Gt�oup Application, this document, the
attached Cover Sheet; the EOC and Schedule of Copayments issued hereunder and the
attached hereto as E�ibit A; the Rate Documents issued by Us in connection with this
Group Agreement and attached hereto as Exhibit B; the Plan Design and Benefit
Summary attached hereto as EYhibit C; and any riders, amendments, inserts or
attachments issued pursuant hereto, all of which are incorporated into or incorpoi•ated by
reference into and made a part of this Group Agreement.
19 "Mandates" means applicable laws, regulations and government requirements in effect
during the Term of this Group Agreement including, without limitation, applicable
Medicare laws, regulations and CMS requirements.
1.10 "Member" is a Medicare beneficiary who: (1) has em�olled in Our Plan and whose
em•ollment in the Plan has been confirmed by CMS, and (2) is eligible to receive
coverage under the Plan, subject to the terms and conditions of the EOC and this Group
Agreement.
1.11 "Party, Parties" means Aetna and Contract Holder.
1.12 "Premium(s)" is defined in the Premiums and Fees section below.
1.13 "Renewal Date" means the fitst day following the end of the Initial Term or any
Subsequent Term.
1.14 "Term" means the Initial Term or any Subsequent Term set forth in the Covei• Sheet to
this Group Agreement.
1.15 Capitalized terms not defined in this Group Agreement shall have the meaning set forth
in the EOC. In the event of a conflict between the terins of this Group Agreeinent and
the terms of the EOC, the terms of this Group Agreement shall prevail.
SECTION 2. COVERAGE
2.1 Covered Benefits. We will provide coverage for Covered Benefits to Membei•s subject
to the terms and conditions of this Group Agreement. Coverage will be pt�ovided in
accordance with the reasonable eYercise of Our business judgment, consistent with
ME PPO GA (Y2013) 2 GRP_12_177
A reinstatement fee as set forth in the Effect of Termination section below.
3.3 Past Due Premiums and Fees. If a Premium payment or any Fees is not paid in full by
Contract Holder on or before the Premium Due Date, a late payment charge in
accordance with Subchapter B of Chapter 2251 of the Govel•nance Code. If all Premiums
and Fees are not received within 31 days following the Premium Due Date (the "Grace
Period"), Contract Holder's failure to make such payment will constitute a breach of this
Group Agreetnent and this Group Agreement will be automatically terminated pursuant
to the Termination by Us section hereof.
If the Group Agreement terminates for any reason, Contract Holder will continue to be
held liable for all Premiums and Fees due and unpaid before the tertnination, including,
but not limited to, Premium payments for any period of time the Group Agreement is in
force during the Grace Period. Members shall also remain liable for Member cost
sharing and other required contributions to coverage for any period of time the Group
Agreement is in force during the Grace Period. We may recover from Contract Holder
Our costs of collecting any unpaid Premiums or Fees, including reasonable attorney's
fees and costs of suit.
3.4 Chan es in Premium._ We may also adjust the Premium rates and/or the manner of
calculating Premiums upon priot• written notice to Contract Holder, provided that such
prior written notice is provided as soon as reasonably possible, but no later than 120 days
prior to the effective date and no such adjustment will be made during the Initial Term
e�cept as provided in the Rate Documents or to reflect changes in applicable law or
regulation or a judicial decision having a material impact on the cost of providing
Covered Benefits to Members.
3.5 Membershin Adiustments. We may, at Our discretion, malce retroactive adjustments to
the Contract Holder's billings for the termination of Members not posted to previous
billings. However, Contract Holder may only receive a maximum of 2 calendar months
credit for Member terminations that occurred more than 30 days before the date Contract
Holder notiiied Us of the termination. We may reduce any such credits by the amount of
any payments We may have made on behalf of such Members (including capitation
payments and other claim payments) befot�e We were informed their coverage had been
terminated. Retroactive additions will be made at Our discretion based upon eligibility
guidelines, as set forth in the EOC, and are subject to the payment of all applicable
Premiums.
3.6 Uniform Preiniums and Low Income Subsidv. Contract Holder shall comply with the
following conditions with respect to any subsidization of that portion of Premiums paid by
Contract Holder for the Medicare Prescription Drug benefit ("MA-PD Premium") and any
required MA-PD Premium contribution by the Member:
• Contract Holder may subsidize diffei•ent amounts of MA-PD Premium for
different ciasses of Members and their dependents, provided such classes are
reasonable and based on objective business criteria, such as years of service,
business location, job categoiy, and nature of compensation (e.g., salaried vs.
ME PPO GA (Y2013) 4 GRP_l2_177
4.2 Waitin� Periocl. Contract Holder may impose a waiting period before individuals are
eligible for coverage under this Group Agreement.
4.3 Eli ibili . Active employees and their dependents at•e not permitted to enroll in the
Plan, unless Contract Holder employs between two and nineteen (2-19) employees. The
number of eligible individuals and eligible dependents and composition of the group, the
identity and status of the Contract Holder, the eligibility requiretnents used to determine
membership in the group, and the participation and contribution standards applicable to
the group which exist at the Effective Date of this Group Agreement are material to the
execution and continuation of this Group Agreement by Us. The Contract Holder shall
not, during the Term of this Group Agreement, modify the Open Enrollment Period or
any other eligibility requirements as described in the EOC and on the Schedule of
Copayments, for the purposes of enrolling Contract Holder's eligible individuals and
eligible dependents under this Group Agreement, unless We agree to the modification in
writing.
SECTION 5. RE5PONSIBILITIES OF THE CONTRACT HOLDER
In addition to other obligations set forth in this Group Agreement, Contract Holder agrees to:
5.1 (A) Records_ Furnish to Us, on a monthly basis (or as otherwise requn•ed), on Our form
(or such other form as We may reasonably approve) by facsimile (or such other means as
We may reasonably approve), such information as We may reasonably require to
administer this Group Agreement. This includes, but is not limited to, information
needed to enroll members of the Contract Holder, process terminations, and effect
changes in family status and transfer of employment of Members.
Contract Holder certiftes, based on best knowledge, information and belief, that all
enrollment and eligibility information that has been or will be supplied to Us is accurate,
complete and truthful. Conti•act Holder acknowledges that We can and will rely on such
enrollment and eligibility infot•mation in determining whether an individual is eligible for
Covered Benefits under this Group Agreement. To the extent such information is
supplied to Us by Contract Holder (in electronic or hard copy format), Contract Holder
agrees to:
• Obtain fi•om all Members a"Disclosure of Healthcare Information" autt�orization
in the form cur�rently being used by Us in tl�e enrollment process (or such otl�er
form as We may reasonably approve).
Maintain a 1•easonably complete record of such infortnation (in electronic or hard
copy format, including evidence of coverage elections, evidence of eligibility,
changes to such elections and terminations) fol• at least ten (10) years and to make
such information available to Us upon request, as required under this Section 5.
We will not be liable to Members for the fulfillment of any obligation prior to
information being 1•eceived in a form satisfactoiy to Us. Contract Holde�• must notify Us
ME PPO GA (Y2013) 6 GRP_12_177
provide Members with written notice describing any changes made to Covered Benefits
at least thirty (30) days prior to the effective date of such change(s) or as required under
Mandates. Contract Holder will provide Members with any written notice required under
Mandates or policies and procedures established by Us in administet•ing and interpreting
this Gi•oup Agreement. The written notices described in this Section are hereinafter
collectively referred to as the "Written Notices". If Contl•act Holder does not distribute
Written Notices to Members as required under this Section 5.4, Contract Holdet� will be
liable to the extent allowed by law for payment of all Premiums or other costs incurred by
Aetna as a result of Contract Holdet•'s failure to distribute the Written Notices. If
Contract Holder does not distribute the Written Notices as required under this Section ,
Aetna may, in its discretion, distribute such Written Notices to Members, and Contract
Holder shall reimburse Aetna to the extent allowed by law for any expenses incurred by
Aetna in connection with such distribution.
CMS requires that all Members receive from Aetna a combined ANOC and EOC no later
than the sooner of: (1) fifteen (15) days prior to the Open Enrollment Period, (2)
September 30th of each calendar year, or (3) such shorter timefi•ame required under
Mandates.
5.5 Member Plan Materials. Contract Holder shall assure that any Member Plan materials
that ha�e not been approved by CMS comply witl� the following alternative disclosure
standards: the Employee Retirement Income Security Act of 1974, as amended
("ERISA") or any alternative disclosure standards applicable to state or local entities that
provide employee h�etiree benefits.
5.6 ERISA Requirements. Maintain responsibility for making reports and disclosures
required by the Employee Retirement Income Security Act of 1974, as amended
(`BRISA"), including the creation, distribution and final content of summaiy plan
descriptions, summary of material modifications and summaty annual reports, unless
Contract Holder's Plan is specifically exempt thereunder.
5.7 Enrollment & Disenrollment Transactions.
(A) Generallv. To the extent that Contt•act Holder directly accepts enrollment and/or
disenrollment requests fi•om Members that Contract Holdei• forwards to Aetna for
processing and submission to CMS, Contract Holder agt�ees to comply with all Mandates
that relate to the handling and processing of enrollment and disenrollment requests that
apply to the Plan ("Enrollment/Disenrollment Requirements"), including, without
limitation, all Eru•olltnent/Disenrollment Requirements that relate to the timeframes that
apply to handling, processing and submission of em•ollment and disenrolltnent requests
for the Plan. Contract Holder agrees to forward enrollment and disenrollment forms
completed by Members to Aetna no later than ninety (90) days after the Metnber's
coverage effective date. Contract Holder acknowledges that if there is a delay between
the time a Member submits an enrollment/disenrollment request to Contract Holder and
when the enrollment/disenrollment request is received by Aetna, the
enl•ollment/disenrollment transaction may not be processed by CMS, unless Aetna
ME PPO GA (Y2013) 8 GRP_12_177
dependents (`Bligible Party" or Eligible Parties") in the Aetna Medicare PPO plan
("Enroll" or "Enrollment") and to electronically terminate the coverage of Members
under the Aetna Medicare PPO plan ("Disenroll" or "Disenrollment"), and Aetna has
agreed to accept Enrollment and Disent�ollment information from Contract Holder
through a roste�• and electronically process such Enrollments and Disenrollments,
Contract Holder must meet certain administrative and legal requirements set forth in this
section of this Group Agreement.
Aetna will electronically Enroll Eligible Parties who have elected tl�e Aetna Medicare
PPO plan covet�age (`Blectronic Em•ollment") and electronically Disenroll Members from
the Aetna Medicare PPO plan (`Blectronic Disent�ollment"), provided Contract Holder
meets the following requll•ements:
• Uses Aetna enrollment and Disenrollment forms approved by CMS for Electronic
Enrollments and Disenrollments ("Aetna Enrollment and Disenrollment Forms").
As permitted under Mandates and this Group Agreement, Contract Holder may
permit Eligible Parties to electronically submit an election form to em�oll in an
Aetna Medicare Plan ("Online Enrollment Form") to Contract Holder ("Online
Election Process").
• Confirms that all Aetna Enrollment and Disenrollment Forms and Online
Enrolltnent Forms contain all data required by CMS, prior to requesting that
Aetna pt'ocess any Electronic Enrollments or Disenrollments.
• Maintains and provides access to all original Aetna Enrollment and Disenrollment
Fortns and Online Eru•ollment Forms completed by Eligible Parties and Members
in accordance with the Recot�ds section of this Group Agreement and all
Mandates.
• Submits Electronic Enrollment and Disenrollments to Aetna timely and accurately
in accordance with Mandates, Aetna policies and procedures, and this Group
Agreement.
• Submits to Aetna all data elements that are required by CMS and Aetna with
respect to each Electronic Enrollment and Disenrollment, including, but not
limited to, the following data elements:
• Name
• Permanent Address
• Medicai•e Claim Number (HICN)
• Gender
• Date of Birth
• Plan Selection
• Pi•ovider Selection (if applicable)
• Group Numbei•
• Class Code
• Plan ID
• Effective Date
ME PPO GA (Y2013) 10 GRP_12_177
SECTION 6. TERMINATION
6.1 Termination bv Contract Holder. This Group Agreement may be terminated by
Contract Holder by pt•oviding Us with 60 days prior written notice ("Notice of
Termination"). The Notice of Termination shall specify the effective date of such
tei•mination, which shall be on the 1 S` day of a calendar month and may not be less than
60 days from the date of the notice, and including the following information: Contract
Holder's name, Contract Holder's Group Number, Service Area(s) (if Contract Holder
elects to terminate the Plan in some, bttt not all, Service Areas covered under this Group
Agreement), Plan name, and the effective date of termination of the Group Agreement.
6.2 Renewal of Group A�reement. This Gt•oup Agreement is renewable annually, unless
Aetna will no longer offer any Aetna Medicare PPO plan in any Service Areas covered
under this Group Agreement, because: (1) CMS terminates or othet�wise non-renews the
Aetna's Medicare Advantage contract witl� CMS, or (2) We terminate Our Medicare
Advantage Contract or reduce the service areas refet•enced in its Medicare Advantage
Contract with CMS.
6.3 Termination bv Us. This Group Agreement will te1•minate immediately upon notice to
Contract Holder as of the last day of the Grace Period if the Premium t•emains unpaid at
the end of the Grace Period.
This Group Agreement may also be terminated by Us as follows:
• Itnmediately upon notice to Contract Holder if Contract Holder has performed
any act or practice that constitutes fraud or made any intentional
misrepresentation of a material fact relevant to the coverage provided under this
Group Agreement;
Immediately upon notice to Contract Holder if Contract Holder no longer has any
enrollee under the Plan who resides in the Service Area;
Upon 30 days written notice to Contract Holder if Contract Holder (i) breaches a
provision of this Group Agreement and such breach remains uncured at the end of
the notice period; (ii) ceases to meet Our requirements for an employer group or
association; (iii) fails to meet Out� contribution or participation requirernents
applicable to this Group Agreement (which contribution and participation
requirements are available upon request); (iv) fails to provide the certification
required by the Policies and Procedures; Compliance Verification Section within
fourteen (14) bLtsiness days of Our request, unless a shorter period of time is
required for Aetna to comply with Mandates; (v) provides written notice to
Membel•s stating that coverage under this Gi•oup Agreement will no longei• be
provided to Members; (vi) changes its eligibility or participation requirements
without Oui• consent or (vii) ceases to meet any Mandates applicable to offering
the Plan to Contract Holdei;
ME PPO GA (Y2013) 12 GRP_12_177
SECTION 8. INDEPENDENT CONTRACTOR RELATIONSHIPS
TNnFMNIFIC'ATTnN
8.1 Relationship Between Us and Networlc Providers. The relationship between Us and
Network Providers is a contractual relationship among independent contractors. Network
Providers are not agents or employees of Us nor are We an agent or employee of any
Networlc Provider.
Network Providers are solely responsible for any health services rendered to their
Members. We make no express or 'rmplied warranties or representations concerning the
qualifications, continued participation, or quality of services of any Network Provider. A
provider's participation in the provider network for the Plan may be terminated at any
time without advance notice to the Contract Holder or Members, subject to applicable
law. Network Providers provide health care diagnosis, treatment and services for
Members. We administer and determine Plan benefits.
8.2 Relationship Between the Parties. The relationship between the Parties is a contractual
relationship between independent contractors. Neither Party is an agent or employee of
the other in performing its obligations pursuant to this Group Agreement.
8.3 Indemnification. Generally, ERISA preempts all non-insurance state laws insofar as
they relate to an employee benefit plan covered by ERISA. In the event this plan meets
the definition of an ERISA Plan pursuant to Section 3(3) of ERISA, there should be no
liability by Us or Contract Holder to third parties pursuant to state law that arises out of
this Group Agreement, Our performance hereunder, or Contract Holder's role as
employer or Plan Sponsor. Nevertheless, in order to fully define indemnity obligations
(a) in light of the possibility of a change in law affecting ERISA preemption of state law
and (b) in the case of an action under ERISA, the parties agree to the following:
We shall indemnify and hold harmless Contract Holder for that portion of any
liability, settlement and related e�pense (including the cost of legal defense)
which was caused solely, directly and independently of all other causes by Our
fraud, willful misconduct, criminal misconduct, negligence, gross negligence, or
material breach of this Group Agreement.
Contract Holder shall, to the extent allowed by law, indemnify and hold harmless
Us, Our affiliates and their respective directors, officers, eligible individuals or
agents, for that portion of any liability, settlement and related expense (including
the cost of legal defense) which was caused by Contract Holder's negligence,
breach of this Group Agreement, breach of applicable Mandates, willful
misconduct, criininal conduct, fraud, or its breach of iiduciary responsibility in
the case of an action under applicable Texas law, related to or arising out of this
Group Agt•eement.
ME PPO GA (Y2013) 14 GRP_l2_177
9.4 Amendments. This Group Agreement may be amended as follows:
• This Group Agreement shall be deemed to be automatically amended to conform
with all Mandates promulgated at any time by any state or federal regulatoiy
agency or authority having supervisory authority over Us; or
By written agreement between both Parties.
The Parties agree that an amendment does not require the consent of any Member or
other person. Except for automatic amendments to comply with law, all amendments to
this Group Agreement must be approved and executed by both Parties. No other
individual has the authority to modify this Group Agreement; waive any of its provisions,
conditions, or restrictions; extend the time for making a payment; or bind Us by malcing
any other commitment or representation or by giving or receiving any information.
9.5 Clerical Errors. Clerical errors or delays by Us in keeping or t�eporting data relative to
coverage will not reduce or invalidate a Member's coverage. Upon discovery of an error
or delay, an adjustment of Premiums shall be made. We may also modify or replace a
Gr•oup Agreement, EOC or other document issued in error.
9.6 Claim Determinations and Administration of Covered Beneiits. We have complete
authority to review all claims for Covered Benefits as defined in the EOC under this
Group Agreement. In exercising such responsibility, We shall have discretionary
authority to determine whether and to what extent eligible individuals and beneficiaries
are entitled to coverage and to construe any disputed or doubtful terms under this Group
Agt'eement, the EOC or any other document incorporated herein. We shall be deemed to
have properly exercised such authority unless We abuse Our discretion by acting
arbitt•arily and capriciously. Our review of claims may include the use of commercial
software (including Claim Check) and other tools to take into account factors such as an
individual's claims history, a providei's billing patterns, compleXity of the service or
treatment, amount of time and degree of slcill needed and the manner of billing. The
administration of Covered Benefits and of any appeals filed by Members related to the
processing of claims for Covered Benefits shall be conducted in accordance with the
EOC and any Mandates.
9.7 Misstatements. If any fact as to the Contract Holder or a Member is found to have been
misstated, an equitable adjustment of Premiums may be made. If the misstatement
affects the existence or amount of coverage, the true facts will be used in determining
whether coverage is or remains in force and its amount.
9.8 Incontestabilitv. Except as to a fraudulent tnisstatement, or issues concerning Premiums
due:
• No statement made by Contract Holdel• or any Membei• shall be the basis for
voiding coverage or denying coverage or be used in defense of a claim unless it is
in writing.
ME PPO GA (Y2013) 16 GRP_12_177
provide or arrange for the provision of services, taking into account the impact of the
event.
9.17 Use of the Aetna Name aud all S mbols Trademarks and Service Marks. We
reserve the right to control the use of Our name and all symbols, trademarks, and service
marlcs presently existing or subsequently established. Contract Holder agrees that it will
not use such name, symbols, trademarks, or service marks in advertising, promotional
materials, or similar materials which describe the Plan without Our prior written consent
and will cease any and all usage immediately upon Our request or upon termination of
this Group Agreement.
9.18 Workers' Compensation. In accordance with 42 C.F.R. Section 422.108, as may be
amended fi•om time to time, and other Mandates, Contract Holder is responsible for
protecting Our interests in any Worlcers' Compensation claims or settlements with any
Member. We shall be reimbutsed for all paid medical expenses which have occurred as a
result of any work related injuiy that is compensable or settled in any manner.
Upon Our request, Contract Holder shall also submit a monthly report to Us listing all
Workers' Compensation cases for Members who have outstanding Workers
Compensation claims involving the Contract Holder. Such list will contain the name,
social security number, date of loss and diagnosis of all applicable Members.
9.19 Medicare Secondary Paver Requirements.
• Generally. Aetna and Contract Holder agree to comply with all Medicare
Secondary Payer ("MSP") Mandates that apply to Contract Holder, the Plan and
Aetna ("MSP Requirements").
MSP Requirements Applicable to Medicare Beneiiciaries Diagnosed with End
Stage Renal Disease (ESRD). Aetna and Contract Holder agree to comply with
all MSP Requirements applicable to Contract Holder's active employees and
retu•ees and theu• dependents who are Medicare beneficiat�ies diagnosed with
ESRD ("ESRD Beneficiaries" or "ESRD Beneficiary"), including, without
limitation, those MSP Requirements set forth in 42 U.S,C. § 1395y(b)(1)(C), 42
C.F.R. §§ 411.102(a), 411.161, and 411.162 and 42 C.F.R. §§ 422.106 and
422.108 ("ESRD MSP Requirements").
Contract Holder acknowledges and agrees that if an ESRD Beneficiary is eligible
for or entitled to Medicare based on ESRD, the MSP Requirements require the
commercial group health plan offered by Contract Nolder ("GHP") to be the
primary payer for the first thirty (30) nlonths of the ESRD Beneficiaiy's Medicare
eligibility or entitlement ("30-month coordination period"), regardless oi the
number of employees employed by Contract Holder and t�egardless of whether the
ESRD Beneficiary is a current employee or retuee.
ME PPO GA (Y2013) 18 GRP_l2_177
Exhibit B: MEDICARE
ADVANTAGE RATE PROPOSAL
Plan Sponsor Name:
Plan Sponsor
Number:
Policy Period Start
Date:
Policy Period End
Date:
Medical Plan:
Hearing Hardware:
Lens
Reimbursement:
♦ Please refer to the Financial Conditions and Plan Design
Exhibits for an outline of the level of benefits quoted, as well
as the terms and conditions of this proposal.
♦ All rates are on a Per Member Per Month (PMPM) basis.
♦ Filed benefits (including copayment amounts), value added
services and premiums are subject to CMS approval, and are
effective January 1, 2013 through December 31, 2013.
♦ All counties are included where Aetna Medicare is available.
These plans are being offered on a national basis.
Assumed enrollment
Total Medical Rate
State
ME PPO GA (Y2013)
New
200
$279.59
Geo
Rating
Area
25%
510
?08.63
Counties
20
50%
845
$193.94
Medicare
Eligible
Members
75%
1,180
$187.59
Medical
Rate
City of Fort
Worth
889000
01/01/2013
12/31 /2013
Medicare
100% Open
ESA PPO
$2,000 / 36
months
Vision 200
100%
1,515
,172.50
GRP_12_177
Kansas 1756 Cowley, Sedgwick 1 $279.59
Bourbon, Clark,
Kentucky 1860 Fayette, Jessamine, 1 $279.59
Scott, Woodford
Barnstable, � $27g.59
Massachusetts 2051 gerkshire
Jefferson, Saint � $27g,59
Missouri 2555 Charles, Saint Louis
Missouri 2562 Ghristian 1 $279.59
Atchison, Bates,
Camden, Grundy,
Harrison, Holt, � $27g.59
Missouri 2569 Jasper, Morgan,
Newton, Phelps,
Tane , Worth
Greene, Oregon,
Missouri 2572 Polk, Saline, � �2�9.59
Webster
Attala, Chickasaw,
Clay, George,
Holmes, Jackson,
Lawrence, Leflore,
Madison, Monroe,
Montgomery, Z $2�g.5g
Mississippi 2654 Neshoba, Noxubee,
Pearl River,
Pontotoc, Prentiss,
Rankin, Scott,
Tippah, Winston,
Yalobusha, Yazoo
Anson, Gaston,
North Carolina 2853 Mecklenburg, 2 �2�9.59
Rowan, Union
New Hampshire 3152 Sullivan 1 $279•59
New Mexico 3353 De Baca, Roosevelt 1 $279.59
Chaves, Dona Ana,
Guadalupe, Lincoln,
New Mexico 3354 Los Alamos, Otero, � �2�9•59
Quay, San Juan,
Union
Ohio 3651 Lorain, Richland 1 $279.59
Butler, Clermont,
Ohio 3658 Hamilton, � $279.59
Montgomery,
Preble, Shelb
Coshocton,
Fai�eld, Fayette,
Ohio 3662 Knox, Madison, 1 $279.59
Morrow, Noble,
Perry, Pickaway
Oklahoma 3753 Cleveland 1 $279.59
Canadian, Mcclain,
Oklahoma 3754 Oklahoma, 1 $279.59
Pottawatomie
ME PPO GA (Y2013) 22 GRP_l2_177
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Texas
Denton, Erath,
4453 Hood, Navarro,
Tarrant, Van Zandt,
Wise
Delta, Ellis,
4454 Hopkins, Johnson,
Kaufman, Parker,
Rains
4455 Collin, Dallas,
Rockwall
4460 Atascosa, Bexar,
Medina
4462 Grimes, Matagorda,
Walker, Wharton
Austin, Harris,
4464 Jasper, Jefferson,
Liberty, Orange,
San Jacinto
4465 Galveston, Hardin
4467 Burnet, Caldwell,
Llano, Williamson
4468 Bastrop, Travis
4469 Hays
Aransas, Duval,
4471 Nueces, San
Patricio
4473 Hamilton, Mills,
Motle
Bosque, Brown,
4474 Hardeman,
Reagan, Ward,
Winkler
Callahan,
4475 Comanche,
Eastland, Ta lor
4476 Jones, Limestone,
Mason, Nolan
Cherokee, Franklin,
Gregg, Harrison,
4481 Marion, Newton,
Red River, Smith,
T ler, U shur
4482 Lamar, Montague,
Wood
4483 Camp, Morris, Titus
Dallam, Jackson,
4485 Lavaca, Madison,
Moore, Parmer,
Victoria
1,076
238
22
5
1
5
1
4
7
1
1
3
12
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
$279.59
5 $279.59
1 $279.59
10 $279.59
12
1
1
$279.59
$279.59
$279.59
ME PPO GA (Y2013) 24 GRP_12_177
Virginia
Washington
4667
4851
Chesapeake City,
Floyd, Franklin,
Galax City,
Grayson, Henry,
King And Queen,
Lancaster,
Martinsville City,
Middlesex,
Portsmouth City,
Smyth,
Southampton,
Suffolk City, Wythe
Adams, Columbia,
Grant, Lewis, Skagit
National Average
1,515
$279.59
$279.59
$279.59
ME PPO GA (Y2013) 26 GRP_12_177
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Table of Contents
2013 Evidence of Covera�e
Table of Contents
This list of chapters and page numbers is your starting point. For more help in finding
information you need, go to the first page of a chapter. You will �nd a detailed list of topics at
the beginning of each chapter.
Chapter 1. Getting started as a member ....................................................................4
Explains what it means to be in a Medicare health plan and how to use this
booklet. Tells about materials we will send you, your plan premiutn, your plan
membership card, and keeping your membership record up to date.
Chapter 2. Important phone numbers and resources ...............................................15
Tells you how to get in touch with our plan (Aetna Medicare Plan (PPO)) and
with other organizations including Medicare, the State Health Insurance
Assistance Program (SHIP), the Quality Improvement Organization, Social
Security, Medicaid (the state health insurance program for people with low
incomes), programs that help people pay for thei�• prescription drugs, and the
Railroad Retirement Board.
Chapter 3. Using the plan's coverage for your medical services ...............................30
Explains iinportant things you need to know about getting your medical care as a
member of our plan. Topics include using the providets in the plan's networlc and
how to get care when you have an emergency.
Chapter 4. Meclical Benefits Chart (what is covered and what you pay) .................41
Gives the details about which types of inedical care are covered and not covered
for you as a member of our plan. Explains how much you will pay as your share
of the cost for your covered medical care.
Chapter 5. Using the plan's coverage for your Part D prescription drugs ...............48
Explains rules you need to follow when you get your Part D drugs. Tells how to
use the plau's List of Covered Dr•ugs (Forn2ulaf y) to find out which drugs are
covered. Tells which kinds of drugs are not covered. Explains several kinds of
restrictions that apply to coverage for certain drugs. Explains where to get your
prescriptions filled. Tells about the plan's programs for drug safety and managing
medications.
Chapter 6. What you pay for your Part D prescription drugs ..................................66
Tells about the four stages of drug coverage (h�itial Cove�°age Stage, Covef�age
Ga� Stcrge, Ccrtastropl�ic Covercrge Stage) and how these stages affect what you
pay for your drugs. Explains the different cost-sharing tiers for your Part D drugs
and tells what you tnust pay for a drug in each cost-sharing tier. Tells about the
late enrollment penalty.
GRP 12 225 D 1 PPO ESA EOC-witl� Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 1: Getting started as a member
Chapter 1 Gettin� started as a member
SECTION 1 Introduction
Section 1.1
Section 1.2
Section 1.3
Section 1.4
Section 1.5
You are enrolled in Aetna Medicare Plan (PPO), which is a
Medicare PPO
What is the Evidence of Cove�°age booklet about?
What does th'rs chapter• tell you?
What if you are new to our plan?
Legal information about the Evidence of Coverczge
SECTION 2 What makes you eligible to be a plan member?
Section 2.1 Your eligibility requirements
Section 2.2 What are Medicare Part A and Medicare Part B?
Section 2.3 The plan service area
SECTION 3 What other materials will you get from us?
Section 3.1 Your plan membership card — Use it to get all covered cai�e and
prescription drugs
Section 3.2 The Providef� Directory: Your guide to all providets and
pharmacies in the plan's network
Section 3.3 The plan's List of Covered Dr•ugs (Formulary)
Section 3.4 The Explcrnation of Benefits (the "EOB"): Reports with a summary
of payments made for your Part D prescription drugs
SECTION 4 Your monthly premium for our plan (if applicable)
Section 4.1 How much is your plan premium?
Section 4.2 There are several ways you can pay your plan premium (if
applicable)
Section 4.3 Can we change your monthly plan premium (if applicable) during
the year?
SECTION 5 Please Iceep your plan membership record up to date
Section 5.1 How to hel� make sure that we have accurate information about
you
SECTION 6 We protect the privacy of your personal health information
Section 6.1 We make sm�e that your health information is protected
SECTION 7 How otlier insurance works with our plan
Section 7.1 Which plan pays first when you have other insurance?
GRP 12 225 D 4 PPO ESA EOC-with Ra (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter l: Getting started as a metnber
Section 1.5 Legal information about the Evidence of Coveruge
It's part of our contract with you
This Evidence of Coverage is part of our contract with you about how our plan covets your care.
Other parts of this contract include your enrollment form, the List of Covered Drzcgs
(Formulary), and any notices you receive fi•om us about changes to your coverage or conditions
that affect your coverage. These notices are sometimes called "riders" or "amendments."
The contract is in effect for months in which you are enrolled in our plan between Januat�y l,
2013 - December 31, 2013.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year.
Your former employer/union/trust can continue to offer you Medicare coverage as a member of
our plan as long as we choose to continue to offer the plan and Medicare renews its approval of
the plan.
SECTION 2
Section 2.1
What makes you eligible to be a plan member?
Your eligibility requirements
You are eligible foy� f�aembership in oz{r� plan as long as:
• You live in the plan service area
• -- crnd -- you are entitled to Medicare Part A
• -- crnd -- you are enrolled in Medicare Part B
Section 2.2 What are Medicare Part A and Medicare Part B?
When you first signed up for Medicar•e, you received information about what services are
covered under Medicare Part A and Medicare Part B. Remember:
• Medicare Part A generally helps cover services furnished by institutional providers such
as hospitals (for inpatient services), skilled nursing facilities, or hotne health agencies.
• Medicare Part B is for most other medical seivices (such as physician's services and
other outpatient services) and certain items (such as durable medical equipment and
supplies).
Section 2.3 The plan service area
Although Medicare is a federal program, our plan is available only to individuals who live in our
plan service area. To reinain a nlembel• of our plan, you mList keep living in this service area. If
you move to olrtside of the service ai•ea, you will have a Special Enrollment Period that will
allow you to switch to a different plan. If you tnove outside of the service area, please contact
Member Services at the telephone number on your member ID card.
GRP 12 225 D 6 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 1: Getting started as a member
and any plan cost sharing as payment in full. We have arranged for these providers to deliver
covered services to members in our plan.
Why do you need to know which providers are part of our network?
As a member of our plan, you may use network providers and out-of-network providers for all
covered medical services at the same member cost sharing amount. Our plan will cover services
fi•om either in-network or out-of-network providers, as long as the services are covered benefits
and medically necessary. See Chapter 3(Using the plan's covercrge for your naedical se�-vices)
for more specific information.
If you live in an Aetna Medicare service area and don't have your copy of the Provider
Directory, you can request a copy from Member Services (phone numbers are printed on the
back of this booklet). You may ask Member Services for more information about our network
providers, including theu� qualifications. You can also see the Pr•ovide�° Directory at
http://www.aetnaretireeplans.com, or download it from this website. Both Member Setvices and
the website can give you the most up-to-date information about changes in our network
providers.
Out-of-network providers must be eligible to receive payment under Medicare and willing to
accept our plan. To find a provider that participates with Original Medicare, go to
www.medicare.�ov.
What are "network pharmacies"?
Our Providef° Directofy gives you a complete list of our network pharmacies — that means all of
the pharmacies that have agreed to fill covered prescriptions for our plan members.
Why do you need to know about network pharmacies?
You can use the Pf�ovider Directory to find the network pharmacy you want to use. This is
impoi•tant because, with few exceptions, you must get your prescr•iptions filled at one of our
network pharmacies if you want our plan to cover (help you pay for) them.
If you don't have the Provider Dir�ectory, you can get a copy from Member Services (phone
numbers are pi•inted on the back cover of this booklet). At any time, you can call Member
Set•vices to get up-to-date information about changes in the pharmacy network. You can also find
this information on our website at http://www.aetnaretireeplans.com.
Section 3.3 The plan's List of Covered Drugs (Formulary)
The plan has a List of Covered Drugs (Formirlary). We call it the "Drug List" for short. It tells
which Pal•t D prescription drugs are covered by our plan. The drugs on this list are selected by
the plan with the help of a team of doctors and pharmacists. Tlie list must ineet requirements set
by Medicare. Medicare has approved the Aetna Medicare Drug List.
The Drug List also tells you if there are any rules that restrict coverage for your drugs.
GRP 12 225 D 8 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 1: Getting started as a member
If you are already enrolled and getting help fi•om one of these programs, the information about
premiums in this Evide�ice of Coverage may not apply to you. We send you a separate insert,
called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription
Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you
about your drug coverage. If you don't have this insert, please call Member Services and ask for
the "LIS Ride1•." (Phone numbers for Member Services are printed on the back cover of this
booklet.)
In some situations, your plan premium could be more
Some members are required to pay a late enrollment penalty because they did not join a
Medicare drug plan when they first became eligible or because they had a continuous period of
63 days or more when they didn't have "creditable" prescription drug coverage. ("Creditable"
means the drug coverage is at least as good as Medicare's standard drug coverage.) For these
members, the late enrollment penalty is added to the plan's monthly premium. Theu• premium
amount will be the monthly plan premium plus the amount of theu late em�ollment penalty.
• If you are required to pay the late enrollment penalty, the amount of your penalty depends
on how long you waited before you em•olled in drug coverage or how many tnonths you
were without drug coverage after you became eligible. Chapter 6, Section 10 explains the
late enrolhnent penalty.
If you have a late enrollment penalty and do not pay it, you could be disenrolled from the
plan.
Many members are required to pay other Medicare premiums
In addition to paying the monthly plan premium (if applicable), many members are required to
pay other Medicare premiums. As explained in Section 2 above, in order to be eligible for our
plan, you must be entitled to Medicare Part A and enrolled in Medicare Part B. For that reason,
some plan members (those who aren't eligible for premium-fi•ee Part A) pay a premium for
Medicare Part A. And most plan members pay a premium for Medicare Part B. You must
continue paying your Medicare premiums to remain a member of the plan.
Some people pay an extra amount for Part D because of their yearly income. If your income is
$85,000 or above for an individual (or married individuals filing separately) or $170,000 or
above for married couples, you must pay an extra amount directly to the government (not the
Medicare plan) for your Medicare Part D coverage.
• If you are required to pay the extra amount and you do not pay it, you will be
disenrolled fro�n the plan and lose prescription drug coverage.
If you have to pay an extra atnount, Social Security, not your Medicare plau, will send
you a letter telling you what that extra amount will be.
� For more infortnation about Part D premiums based on income, go to Chapter 4, Section
11 ofthis boolclet. You can also visit http:Uwww.medicare.gov on the web or call 1-800-
MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-
877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY useis should
call 1-800-325-0778.
GRP 12 225 D 10 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 1: Getting started as a member
At the time we end your membership, you may still owe us for premiums you have not paid. In
the future, if you want to enroll again in our plan (or another plan that we offer), you may need to
pay the amount you owe before you can enroll.
If you think we have wrongfully ended your membership, you have a right to ask us to
reconsider this decision by making a complaint. Chapter 9, Section 10 of this booklet tells how to
make a complaint. If you had an emergency circumstance that was out of your control and it
caused you to not be able to pay your premiums within our grace period, you can ask Medicare
to reconsidet• this decision by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. TTY users should call 1-877-486-2048.
Section 4.3 Can we change your monthly plan premium (if applicable) cluring the
year?
No. We are not allowed to change the amount we charge for the plan's monthly plan premium
during the year. If the monthly plan premium changes for next year the change will take effect on
January 1 st.
However, in some cases the part of the premium that you have to pay can change during the year.
This happens if you become eligible for the Extra Help program or if you lose your eligibility for
the Extra Help program during the year. If a member qualifies for Extra Help with their
prescription drug costs, the E�tra Help program will pay part of the member's monthly plan
premium. So a member who becomes eligible for Extr•a Help during the year would begin to pay
less towards their monthly premium. And a member who loses their eligibility during the year
will need to start paying their full monthly premium. You can find out more about the Extra Help
program in Chapter 2, Section 7.
SECTION 5 Please keep your plan membership record up to date
Section 5.1 How to help make sure that we have accurate information about you
Your membership record has information fi•om your enrollment form, including your address and
telephone number. It shows your specific plan coverage including your Primaty Care
Provider/Medical Group/IPA. (An IPA, or Independent Practice Association, is an independent
group of physicians and other health-care providers under contt•act to provide services to
members of managed care organizations.)
The doctors, hospitals, pharmacists, and other providers in the plan's network need to have
correct information about you. These network providers use your membership record to
know what services and drugs are covered and the cost-sharing amounts for you. Because
of this, it is very important t11at you help us keep your information up to date.
Let us Icnow about these changes:
• Changes to your name, your address, or yow• phone number
• Changes in any other health insurance coverage you have (such as fi•om your employer,
your spouse's employer, workers' compensation, or Medicaid)
GRP 12 225 D l2 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 1: Getting started as a member
• If you're under 65 and disabled and you or your family member is still working,
your plan pays fit•st if the employer has 100 or more employees or at least one
employer in a multiple employer plan has more than 100 employees.
� If you're over 65 and you or yout� spouse is still worlcing, the plan pays first if the
employer has 20 or more employees or at least one employer in a multiple
employer plan has more than 20 employees.
If you have Medicare because of ESRD, your group health plan will pay first for the first
30 months after you become eligible for Medicare.
These types of coverage usually pay first for sei•vices related to each type:
• No-fault insurance (including automobile insurance)
• Liability (including automobile insurance)
• Black lung benefits
• Workers' compensation
Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.
If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about
who pays first, or you need to update your other insurance information, call Member Services
(phone numbers are printed on the back of your member ID card). You may need to give your
plan member ID number to your other insurers (once you have confrmed their identity) so your
bills are paid correctly and on time.
GRP 12 225 D 14 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 2: Important phone numbers and resources
SECTION 1 Aetna Medicare contacts (how to contact us, including how to
reach Member Services at the plan)
How to contact our plan's Member Services
For assistance with claims, billing or member caed questions, please call or write to Aetna
Medicare Member Services. We will be happy to help you.
Member Services
_
CALL Please call the telephone number printed on the back of your member ID
card. Or for questions regarding your medical benefits, call our general
customer selvice center at 1-888-267-2637. For questions regarding your
prescription drug benefits, call 1-800-594-9390.
Calls to these numbers are free. Hours of operation: Monday tl�u�ough
Friday, 8 a.m. to 6 p.m. in all time zones.
Member Services also has fi•ee language interpreter services available for
non-English speakers.
TTY 711
This number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.
Calls to this number are fi�ee. Hours of operation: Monday through
Friday, 8 a.m. to 6 p.m. in all time zones.
WRITE Aetna Medicare
P.O. Box 14088
Lexington, KY 40512-4088
WEBSITE www.aetnaretireeplans.com
How to contact us when you are asking for a coverage decision about your medical care
A covei•age decision is a decision we make about your benefits and coverage or about the amount
we will pay for your medical se�vices. For more information on asking for coverage decisions
about youi• medical care, see Chapter 9(tiVhat to do if you have a pf°oblem or complcrint
(covef°age decisions, appeals, cor��plaints)).
You may call us if you have questions about our coverage decision process.
GRP 12 225 D 16 PPO ESA EOC-with R1(Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 2: Important phone numbets and resources
F� 1-866-604-7092
WRITE Aetna Medicare Grievance & Appeal Unit
P.O. Box 14067
Lexington, KY 40512
AETNA You can submit an appeal about our plan online. To submit an online appeal
WEBSITE go to:
http://www.aetnamedicare.com/plan_cho ices/advantage_appeal s_grievances. j
sp
How to contact us when you are making a complaint about your medical care
You can make a complaint about us or one of our network providers, including a complaint
about the quality of yout• care. This type of complaint does not involve coverage or payment
disputes. (If your problem is about the plan's coverage or payment, you should look at the
section above about making an appeal.) For more information on malcing a complaint about your
medical cai•e, see Chapter 9(What to c�o f you have a problem or conaplaint (coverage clecisions,
appeals, conzplaints)).
Complaints about Medical Care
�
� , ,� _
CALL Please call the telephone number printed on the back of your member I
card or our general customer service center at 1-888-267-2637.
Calls to this number are fi•ee. Hours of operation: Monday through Friday, 8
a.m. to 6 p.m. in all time zones.
TTY 711
This number requires special telephone equiptnent and is only for people
who have difficulties with hearing or speaking.
Calls to this number are fi•ee. How�s of operation: Monday through Friday, 8
a.m. to 6 p.m. in all time zones.
F� 1-866-604-7092
WRITE Aetna Medicare Grievance & Appeal Unit
P.O. Box 14067
Lexington, KY 40512
AETNA You can submit a complaint about our plan online. To submit an online
VVEBSITE complaint go to:
GR3' 12 225 D 18 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 2: Important phone numbers and resources
Appeals for Part D Prescription Drugs
CALL
TTY
FAX
WRiTE
1-877-235-3755 for Expedited Appeals Only
Calls to this number are fi•ee. Hours of operation: 7 days per week, 8 a.m. to 8
p.m.
711
This number requires special telephone equipment and is only for people who
ha�e difficulties with hearing or speaking.
Calls to this number are ft•ee. Hours of operation: 7 days per week, 8 a.m. to 8
p.m.
1-866-604-7092
Aetna Medicare Pharmacy Grievance and Appeals Unit
P.O. Box 14579
Lexington, KY 40512
WEBSITE You can submit an appeal online. To submit an online appeal go to:
http://www.aetnamedicare.com/plan_choices/advantage_appeals_grievances. j
sp
How to contact us when you are making a coinplaint about your Part D prescription drugs
You can make a complaint about us or one of our network pharmacies, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If your probletn is about the plan's coverage or payment, you should look at the
section above about making an appeal.) For more information on making a complaint about your
Part D prescription drugs, see Chapter 9(What to do if you have a p��oblenz or complaint
(coverage decisions, appeals, complaints)).
Complaints about Part D prescription drugs
CALL
Please call the telephone number printed on the back of your member ID
card or our member service center at 1-800-594-9390.
Calls to this nunlber ai•e free. Hours of operation: Monday through Friday, 8
a.m. to 6 pm. in all time zones.
GRP 12 225 D 20 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 2: Important phone numbers and resources
, _ ,.
���� � � EI Paso, TX 79998-ll 06
SECTION 2 Medicare (how to get help and information directly from the
federal Medicare program)
Medicare is the federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure t•equiring dialysis or a kidney transplant).
The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services
(sometimes called "CMS"). This agency contracts with Medicare Advantage organizations
including us.
Medicare
CALL 1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.
TTY 1-877-486-2048
This number requires special telephone equipment and is only for people
who have difficulties with hearing or speaking.
Calls to this number are fi•ee.
WEBSITE http://www.medicare.gov
This is the official government website for Medicare. It gives you up-to-
date information about Medicare and current Medicat�e issues. It also has
information about hospitals, nursing homes, physicians, home health
agencies, and dialysis facilities. It includes booklets you can print directly
fi�om your computer. You can also find Medicare contacts in your state.
The Medicare website also has detailed information about your Medicare
eligibility and enrollment options with the following tools:
• Medicare Eligibility Tool: Provides Medicare eligibility status
information.
• Medicare Plan Finder: Provides pei•soualized information about
available Medicare prescription drug plans, Medicare health
plans, and Medigap (Medicare Supplement Insurance) policies in
your area. These tools provide an esti»tate of what your out-of-
nocket costs might be in different Medicare plans.
GRP 12 225 D 22 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 2: Impot•tant phone numbers and resources
care for people with Medicare. A QIO is an independent organization. It is not connected with
our plan.
You should contact the QIO in your� state in any of these situations:
• You have a complaint about the quality of care you have received.
You think coverage for your hospital stay is ending too soon.
You think coverage for your home health care, skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.
SECTION 5 Social Security
Social Security is responsible for determining eligibility and handling enrollment for Medicare.
U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal Disease and meet
certain conditions, are eligible for Medicar•e. If you are ah�eady getting Social Security checks,
enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to
enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for
Medicare, you can call Social Security or visit your local Social Security office.
Social Security is also responsible for determining who has to pay an extra amount for their Part
D drug coverage because they have a higher income. If you got a letter fi•om Social Security
telling you that you have to pay the extra amount and have questions about the amount or if your
income went down because of a life-changing event, you can call Social Security to ask for a
reconsideration.
. r � � , f. . �
ki Social Security '
�3 . . .. . - '� �� �� �� ?
; CALL 1-500-772-1213 ��
f�
� Calls to this number are free. ;
;� �;
�
fi� Available 7:00 am to 7:00 pm, Monday through Fr�iday.
,�
� You can use Social Security's automated telephone services to get �
' recorded information and conduct some business 24 hours a day.
F$
,
�,
'F` TTY 1-800-325-0778
.3
� This number requires special telephone equipment and is only for people °�
� who have difficulties with hearing or spealcing. �
i:
��
�� Calls to this number are fi•ee. �
�, �
�` s
� Available 7:00 am to 7:00 pm, Monday through Friday. „
3
; ,;
,� _
;
GRP 12 225 D 24 PPO ESA EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Chapter 2: Important phone numbers and resources
• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours
a day, 7 days a week;
• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through
Friday. TTY users should call 1-800-325-0778; or
Your State Medicaid Office. (See Section 6 of this chapter for contact information.)
If you believe you have qualified for EYtra Help and you believe that you are paying an incorrect
cost-shar•ing amount when you get your prescription at a pharmacy, our plan has established a
process that allows you to either request assistance in obtaining evidence of your proper co-
payment level, or, if you already have the evidence, to provide this evidence to us.
• While you are at the pharmacy, you can ask the pharmacist to contact Aetna at the
number on your ID card. If the situation cannot be resolved at that time, Aetna will give
you a one-time exception and you will be charged the copayment/coinsurance amount
that you were given by CMS. This exception is temporaty and lasts 21 days. Aetna will
permanently update our systems upon the receipt of one of the acceptable forms of
evidence listed below.
You can fax your evidence to Aetna at 1-888-665-6296, or mail your documentation to:
Aetna Medicare Department
Attention: BAE
P.O. Box 14088
Lexington, KY 40512-4088
Examples of evidence can be any of the following items:
• A copy of your Medicaid card that includes your name and an eligibility date
during a month after lune of the previous calendar year
• A copy of a state document that confirms active Medicaid status during a month
after June of the previous calendar• year
• A print out fi•om the state electronic enrollment file showing Medicaid status
during a month after June of the previous calendar year
• A screen print from the state's Medicaid systems showing Medicaid status during
a month after June of the previous calendar year
• Other documentation provided by the state showing Medicaid status dur'rng a
month after June of the previous calendar year
• For individuals who ar•e not deemed eligible, but who apply and are found LIS
eligible, a copy ofthe SSA award letter
• If you are institutionalized and qualify for zero cost-sharing:
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Chapter 2: Important phone numbers and resources
If you reach the coverage gap, we will automatically apply the discount when your pharmacy
bills you for youi� pi�esci•iption and your Explanation of Benefits (EOB) will show any discount
provided. Both the amount you pay and the amount discounted by the manufacturer count toward
your out-of-pocket costs as if you had paid them and moves you through the coverage gap.
You also receive some covet•age for generic drugs. If you reach the coverage gap, the plan pays
21 % of the price fot• generic dt•ugs and you pay the remaining 79% of the price. The coverage for
generic drugs works differently than the coverage for brand name drugs. For generic drugs, the
amount paid by the plan (21 %) does not count toward your out-of-pocket costs. Only the amount
you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as
part of the cost of the drug.
If you have any questions about the availability of discounts for the drugs you are taking or about
the Medicare Coverage Gap Discount Program in general, please contact Member Services
(phone numbers are printed on the back cover of this booklet).
What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?
If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program
that provides coverage for Part D drugs (other than Extra Help), you still get the 50% discount on
covered brand name drugs. Also, the plan pays 2.5% of the costs of brand drugs in the coverage
gap. The 50% discount and the 2.5% paid by the plan is applied to the price of the drug before
any SPAP or other coverage.
What if you get Extra Help from Medicare to help pay your prescription drug costs? Can
you get the discounts?
No. If you get Extra Help, you already get coverage for your prescription drug costs during the
coverage gap.
What if you don't get a discount, and you think you should have?
If you think that you have reached the coverage gap and did not get a discount when you paid for
your brand name drug, you should review your next Explanation of Benefits (EOB) notice. If the
discount doesn't appear on your Explanation of Bene�ts, you should contact us to make sure that
your prescription records are correct and up-to-date. If we don't agree that you are owed a
discount, you can appeal. You can get help filing an appeal from your State Health Insurance
Assistance Program (SHIP) (telephone numbers are in Addendum A at the end of this Evidence
of Cover�crge) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
State Pharmaceutical Assistance Programs
Many states have State Phai•maceutical Assistance Programs that help some people pay for
prescription drugs based on financial need, age, or medical condition. Each state has different
rules to provide drug coverage to its members.
These programs provide limited income and medically needy seniors and individuals with
disabilities financial help for prescription drugs. Refer to Addendum A at the bacic of this
Evidence of Coverage to identify if there is an SPAP in your state.
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Chapter 3: Using the plan's coverage for your medical setvices
Chapter 3 Usin� the plan's covera�e for vour medical services
SECTION 1 Things to know about getting your medical care covered as a member of our
plan
Section 1.1 What are "networlc providers" and "covered seivices"?
Section 1.2 Basic rules for getting your medical care covered by the plan
SECTION 2 Using network and out-of-networlc providers to get your medical care
Section 2.1 You may choose a Primary Care Provider (PCP) to provide and
oversee your medical care
Section 2.2 How to get care from specialists and other network providers
Section 23 How to get care from out-of-network providers
SECTION 3 How to get covered services when you have an emergency or urgent need for
care
Section 3.1 Getting care if you have a medical emergency
Section 3.2 Getting care when you have an urgent need for care
SECTION 4 What if you are billed directly for the full cost of your covered services?
Section 4.1 You can ask us to pay our share of the cost of covered services
Section 4.2 If services are not covered by our plan, you must pay the full cost
SECTION 5 How are your medical services covered when you are in
study"?
Section 5.1 What is a"clinical research study"?
Section 5.2 When you participate in a clinical research
what?
a "clinical research
study, who pays for
SECTION 6 Rules for getting care covered in a"religious non-medical health care
institution"
Section 6.1 What is a religious non-medical health care institution?
Section 6.2 What care from a religious non-tnedical health care institution is
covered by our plan?
SECTION 7 Rules for ownership of durable medical equipment
Section 7.1 Will you own the durable medical equipment after making a
certain number of payments under our plan?
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Chapter 3: Using the plan's coverage for your medical services
• You receive your care from a provider who participates in Medicare. As a member
of our plan, you can receive your care from either a network provider or an out-of-
network provider (for more about this, see Section 2 in this chapter).
• The providers in our network are listed in the Pf�ovider Directory.
Please note: While you can get your care from an out-of-network provider, the provider must be
eligible to participate in Medicare. We cannot pay a provider who is not eligible to participate in
Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be
responsible for the full cost of the services you receive. Checic with your provider before
receiving services to confirtn that they are eligible to participate in Medicare.
SECTION 2
Section 2.1
Using network and out-of-network providers to get your
medical care
You may choose a Primary Care Provider (PCP) to provide and
oversee your medical cai•e
What is a"PCP" and what does the PCP do for you?
When you become a member of our plan, you do not have to choose a plan provider to be your
PCP, however we encourage you to do so by calling Member Services and designating your
choice of a PCP. By having a PCP coordinate yow• care, you may benefit by receiving care from
a doctor that has a deeper understanding of youi� health care needs and may be able to assist with
important medical decisions. A PCP is a physician who meets state requirements and is trained to
give you routine medical care. A PCP could provide most of your care and can help you at•range
or coordinate the rest of the covered services you get as a member of our plan. This includes:
• x-rays
• laboratoiy tests
• therapies
• care fi�om doctors who are specialists
• hospital admissions, and
• follow-up care.
"Coordinating" your services includes referj•ing and consulting with other plan providers about
youi• health care needs. If you need certain types of covered services or supplies, your PCP may
need to obtain approval in advance fi�om Aetna. Since your PCP will provide and coordinate your
medical care, you should have all of your past medical records sent to your PCP's office.
How do you choose your PCP?
You may select a network PCP at the time of enrollment or at any other time. You can select a
PCP fi•om either the provider directoiy or by calling Member Seivices, anytime, for assistance.
You can also select a PCP by accessing our online providei• directory, DocFind, at:
http://www.aetnaretireeplans.com. If there is a particular plan specialist or hospital that you want
to use, check first to be sure that your PCP makes referrals to that specialist, or uses that hospital.
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Chapter 3: Using the plan's coverage for your medical seivices
• You can get your care fi�om an out-of-network provider, however, that provider must be
eligible to participate in Medicare. We cannot pay a provider who is not eligible to
participate in Medicare, If you receive care fi�om a provider who is not eligible to
participate in Medicare, you will be responsible for the full cost of the services you
receive. Checic with your provider before receiving services to confirm that they are
eligible to participate in Medicare.
You don't need to get a referral or priot� authorization when you get care from out-of-
network providers. However, before getting services from out-of-network providers you
may want to ask for a pre-visit coverage decision to confirm that the services you are
getting are covered and are medically necessary. (See Chapter 9, Section 4 for
information about asking for coverage decisions.) This is important because:
• Without a pre-visit coverage decision, if we later determine that the seivices are
not covered or were not medically necessary, we may deny coverage and you will
be responsible for the entire cost. If we say we will not cover your services, you
have the right to appeal our decision not to cover your care. See Chaptet• 9(What
to do if you have a problen� or complaint) to learn how to make an appeal.
It is best to ask an out-of-network provider to bill the plan first. But, if you have alt�eady
paid for the covered seivices, we will reimburse you for our share of the cost for covered
services. Or if an out-of-network provider sends you a bill that you thinlc we should pay,
you can send it to us for payment. See Chapter 7(Asking zis to pay our� share of a bill yoi�
have f°eceivecl for covered nzedical services or drzcgs) for information about what to do if
you receive a bill or if you need to ask for reimbursement.
SECTION 3 How to get covered services when you have an emergency
or urgent need for care
Section 3.1 Getting care if you have a medical emergency
What is a"medical emergency" and what should you do if you have one?
A"medical emergency" is when you, or any other prudent layperson with an average
knowledge of health and medicine, believe that you have medical symptoms that requ've
immediate medical attention to prevent loss of life, loss of a litnb, or loss of function of a limb.
The medical symptoms may be an illness, injmy, severe pain, or a medical condition that is
quickly getting worse.
If you have a medical emergency:
• Get help as quickly as possible. Call 911 for help or go to the nearest emergency room
or hospital. Call for an ambulance if you need it. You do not need to get approval or a
referral first from your PCP.
� As soon as possible, malce sure that our plan has been told about your emergency.
We need to follow up on your emergency care. You or someone else should call to tell us
about your emergency care, usually within 48 hours. Please call Member Setvices at the
number on your ID card.
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Chapter 3: Using the plan's coverage for your medical services
SECTION 4 What if you are billed directly for the full cost of your
covered services?
Section 4.1 You can ask us to pay our share of the cost of covered services
If you have paid more than your share for covered services, or if you have received a bill for the
full cost of covered medical services, go to Chapter 7(Askin�g zrs to pay our share of c� bill yoz�
have f°eceivecl for covered mec�ical sen�ices or drzrgs) for information about what to do.
Section 4.2 If services are not covered by our plan, you must pay the full cost
Our plan covers all medical services that are medically necessary, are listed in the plan's Medical
Benefits Chart (this chart is included with this Evidence of Coverage), and are obtained
consistent with plan rules. You are responsible for paying the full cost of services that aren't
covered by our plan, either because they are not plan covered services, or plan rules were not
followed.
If you have any questions about whether we will pay for any medical service or care that you are
considering, you have the right to ask us whether we will cover it before you get it. If we say we
will not cover your services, you have the right to appeal our decision not to cover your care.
Chapter 9(What to do if yoz� have a problen7 or complaint (coverage decisions, appeals,
con�plaints)) has more information about what to do if you want a coverage decision from us or
want to appeal a decision we have ah�eady made. You may also call Member Services to get
more information about how to do this (phone numbers are printed on the back cover of this
booklet).
For covered services that have a benefit limitation, you pay the full cost of any services you get
after you have used up your benefit for that type of covered service.'Paying for costs once a
benefit limit has been reached will not count toward an out-of-pocicet maximum limit. You can
call Member Services when you want to know how much of your beneiit limit you have already
used.
SECTION 5
Section 5.1
How are your medical services covered when you are in a
"clinical research study"?
What is a"clinical research study"?
A clinical reseaech study (also called a"clinical trial") is a way that doctors and scientists test
new types of inedical care, like how well a new cancer drug works. They test new medical care
procedures or drugs by asking for volunteers to help with the study. This kind of study is one of
the final stages of a research process that helps doctors and scientists see if a new approach
works and if it is safe.
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Chapter 3: Using the plan's coverage for your medical services
Here's an exan�ple of ho�-v the cost sharing �vor•ks: Let's say that you have a lab test that costs
$100 as part of the research study. Let's also say that your share of the costs for this test is $20
under Original Medicare, but the test would be $10 under our plan's benefits. In this case,
Ot�iginal Medicare would pay $80 for the test and we would pay another $10. This means that
you would pay $10, which is the same amount you would pay undet• our plan's benefits.
In order for us to pay for ow� shaee of the costs, you will need to submit a request for payment.
With your request, you will need to send us a copy of your Medicare Summary Notices or other
documentation that shows what services you received as part of the study and how much you
owe. Please see Chapter 7 for more information about submitting requests for payment.
When you are part of a clinical research study, neither Medicare nor our plan will pay for any
of the following:
• Generally, Medicare will not pay for the new item or service that the study is testing
unless Medicare would cover the item or service even if you were not in a study.
Items and services the study gives you or any participant for free.
Items or services provided only to collect data, and not used in your direct health care.
For example, Medicare would not pay for monthly CT scans done as part of the study if
your medical condition would normally require only one CT scan.
Do you want to know more?
You can get more information about joining a clinicat research study by reading the publication
"Medicare and Clinical Research Studies" on the Medicare website (http://www.medicare.gov).
You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.
SECTION 6
Section 61
Rules for getting care covered in a"religious non-medical
health care institution"
What is a religious non-medical health care institution?
A religious non-medical health ca1�e institution is a facility that provides care for a condition that
would ordinarily be treated in a hospital or skilled nursing facility care. If getting care in a
hospital or a skilled nursing facility is against a member's religious beliefs, we will instead
provide coverage for care in a religious non-medical health care institution. You may choose to
putsue medical care at any time for any reason. This benefit is provided only for Part A inpatient
services (non-medical health care services). Medicare will only pay for non-medical health care
setvices provided by t�eligious non-medical health care institutions.
Sectiov 6.2 What care from a religious non-medical health care institution is
covered by our plan?
To get cai•e from a religious non-medical health care institution, you must sign a legal document
that says you are conscientiously opposed to getting medical treatment that is "non-excepted."
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Chapter 3: Using the plan's coverage for your medical services
What happens to payments you have made for durable medical equipment if you switch to
Original Medicare?
If �u switch to Ori inal Medicare after bein� a member of our plan: If you did not acquire
ownership of the durable medical equipment item while m our plan, you will have to make 13
new consecutive payments for the item while in Original Medicare in order to acquire ownership
of the item. Your previous payments while in our plan do not count toward these 13 consecutive
payments.
If you made payments for the durable medical equipment item under Original Medicare befo�°e
you joined our plan, these previous Ot•iginal Medicare payments also do not count toward the 13
consecutive payments. You will have to make 13 consecutive payments for the item under
Original Medicare in order to acquire ownership. There are no eYceptions to this case when you
return to Original Medicare.
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Chapter 4: Medical Benefits Chart (what is covered and what you pay)
SECTION 1 Understanding your out-of-pocket costs for covered services
This chapter focuses on your covered set•vices and what you pay for your medical beneiits. It
describes a Medical Benefits Chart that lists your covered services and shows how much you
will pay for each covet•ed seivice as a member of our plan. The Medical Benefits Chart is
included with and is part of this Evidence of Coverage. (This benefits chart is also referred to as
Aetna's Schedule of Copayments/Coinsurance.) Later in this chapter, you can find infol•mation
about medical services that are not covered. It also explains limits on certain services.
Section 1.1 Types of out-of-pocket costs you may pay for your covered services
To understand the payment information we give you in this chapter, you need to know about the
types of out-of-pocket costs you may pay for your covered services.
• The "deductible" is the amount you must pay for medical services before our plan begins
to pay its share. (Section 1.2 tells you more about yom� yearly plan deductible.)
A"copayment" is the fixed amount you pay each time you receive cet�tain medical
services. You pay a copayment at the time you get the medical service. (The Medical
Benefits Chart tells you more about your copayments.)
��Coinsurance" is the percentage you pay of the total cost of certain medical seivices.
You pay a coinsurance at the time you get the medical service. (The Medical Benefits
Chart tells you more about youi� coinsurance.)
Some people qualify for State Medicaid programs to help them pay their out-of-pocket costs for
Medicare. (These "Medicare Savings Pt�ograms" include the Qualified Medicare Beneficiary
(QMB), Specified Low-Income Medicare Beneficiaty (SLMB), Qualifying Individual (QI), and
Qualified Disabled & Working Individuals (QDWI) programs.) If you are enrolled in one of
these programs, you may still have to pay a copayment for the service, depending on the rules in
your state.
Section 1.2 What is your yearly plan deductible?
Your plan may include a deductible amount for services received fi�om both in-network and out-
of-network providers. This is the amount you have to pay out-of-pocket before our plan pays its
share for your covered medical services. Please refer to the first page of your Medical Benefits
Chart (Schedule of Copayments/Coinsurance) for your applicable deductible amount.
Until you have paid the deductible amount, you must pay the full cost for most of your covered
services. Once you have paid your deductible, we will begin to pay our share of the costs for
covered medical services and you will pay your share (your copayment or coinsurance amount)
for the rest of the calendar year.
The deductible does not apply to some services. This means that we will pay our share of the
costs for these services even if you haven't paid your yearly deductible yet. Refer to page 1 of
the Medical Benefits Chai•t for a full list of services that are not subject to the plan deductibles.
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Chapter• 4: Medical Benefits Chart (what is covered and what you pay)
Here is how this protection works.
• If your cost shaeing is a copayment (a set amount of dollars, for example, $15.00), then
you pay only that amount for any covered services fi�om a network provider.
If your cost sharing is a coinsut•ance (a percentage of the total charges), then you never
pay more than that percentage. However, your cost depends on which type of provider
you see:
• If you obtain covered seivices fi�om a network provider, you pay the coinsurance
percentage rnultiplied by the plan's reimbursement rate (as determined in the
contract between the provider and the plan).
If you obtain covered services from an out-of-network provider who participates
with Medicare, you pay the coinsurance percentage multiplied by the Medicare
payment rate for participating providers.
If you obtain covered services fi�om an out-of-network provider who does not
participate with Medicare, then you pay the coinsurance amount multiplied by the
Medicare payment rate for non-participating provideis.
SECTION 2 Use the Medical Benefits Chart to iind out what is covered
for you and how much you will pay
Section 2.1 Your medical beneiits and costs as a member of the plan
The Medical Benefits Chart (also referred to as the Aetna Schedule of Copayments/
Coinsurance) included with this Evic�ence of Cove�°age lists the services our plan covers and what
you pay out-of-pocket for each service. The services listed in the Medical Benefits Chart are
covered only when the following coverage requirements are met:
• Your Medicare covered services must be provided according to the coverage guidelines
established by Medicare.
Your services (including medical care, services, supplies, and equipment) nncst be
medically necessary. "Medically necessary" means that the services, supplies, or drugs
are needed for the prevention, diagnosis, or treatment of your medical condition and meet
accepted standards of inedical practice.
Some of the services listed in the Medical Benefits Chart are covered as in-network
services only if your doctoi• or other network provider gets approval in advance
(sometimes called "prior authorization") from Aetna Medicare.
• Covered services that need appi•oval in advance to be covered as in-network
services are marlced by an asterisk and footnote in the Medical Benefits Chart.
You never need approval in advance for out-of-network setvices from out-of-
netwot•k providers.
While you don't need appl•oval in advance for out-of-network services, you or
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Chapter 4: Medical Benefits Chart (what is covered and what you pay)
this Evidence of Coverage, the following items and services aren't covered under Original
Medicare or by our plau:
• Services considered not reasonable and necessary, according to the standards of Original
Medicare, unless these services are listed by our plan as covered services.
• Experimental medical and surgical procedures, equipment and medications, unless
covered by Original Medicare or under a Medicare-approved clinical research study or by
our plan. (See Chapter 3, Section 5 for more information on clinical research studies.)
Experimental procedures and items are those items and procedures determined by our
plan and Original Medicare to not be generally accepted by the medical community.
• Surgical treatment for morbid obesity, except when it is considered medically necessary
and covered under Original Medicare.
• Private room in a hospital, except when it is considered medically necessary.
• Private duty nurses unless purchased as additional plan coverage by your
employer/union/trust group plan.
• Personal items in your room at a hospital or a skilled nut•sing facility, such as a telephone
or a television.
• Full-time nursing care in your home.
• Custodial care is care provided in a nursing home, hospice, or other facility setting when
you do not require skilled medical care or skilled nursing care. Custodial care is petsonal
care that does not require the continuing attention of trained medical or paramedical
personnel, such as care that helps you with activities of daily living, such as bathing ot•
dressing.
• Homemaker services include basic household assistance, including light housekeeping ot�
light meal pi•eparation.
• Fees charged by your immediate relatives or members ofyour household.
• Meals delivered to your home.
• Elective or voluntary enhancement procedures oi• services (including weight loss, hair
growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and
mental performance), except when medically necessary.
• Cosmetic stu•gery or procedures, unless because of an accidental injury or to improve a
malforined part of the body. However, all stages of reconstruction are covered for a
breast after a tnastectomy, as well as for the unaffected breast to produce a symmetrical
appearance.
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Chapter 5: Using the plan's coverage for your Part D pt'escription drugs
Chapter 5 Usin� the plan's covera�e for vour Part D prescription dru�s
SECTION 1 Introduction
Section 1.1 This chapter describes your coverage fo7• Part D drugs
Section 1.2 Basic rules for the plan's Part D drug coverage
SECTION 2 Fill your prescription at a networlc pharmacy or through the plan's mail-
orcler service
Section 2.1 To have your prescription covered, use a netwot�k pharmacy
Section 2.2 Finding network pharmacies
Section 2.3 Using the plan's mail-order services
Section 2.4 How can you get a long-term supply of drugs?
Section 2.5 When can you use a pharmacy that is not in the plan's network?
SECTION 3 Your drugs need to be on the plan's "Drug List"
Section 3.1 The "Drug List" tells which Part D drugs are covered
Section 3.2 There are different "cost-sharing tieis" for drugs on the Drug List
Section 3.3 How can you find out if a specific drug is on the Drug List?
SECTION 4 There are i•estrictions on coverage for some drugs
Section 4.1 Why do some drugs have restrictions?
Section 4.2 What kinds of restrictions?
Section 4.3 Do any of these restrictions apply to your drugs?
SECTION 5 What if one of your drugs is not covered in the way you'd like it to be
covered?
Section 5.1 There are things you can do if your drug is not covered in the way
you'd lilce it to be covered
Section 5.2 What can you do if your drug is not on the Drug List or if the drug
is restricted in some way?
Section 5.3 What can you do if your drug is in a cost-sharing tier you think is
too high?
SECTION 6 What if your coverage changes for one of your drugs?
Section 6.1 The Drug List can change during the year
Section 6.2 What happens if coverage changes for a drug you are taking?
SECTION 7 What types of drugs are rrot covered by the plan?
Section 7.1 Types of drugs we do not cover
SECTION 8 Show your plan membership card when you iill a prescription
Section 8.1 Show your membership card
Section 8.2 What if you don't have yout� membership card with you?
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Chapter 5: Using the plan's coverage for your Part D prescr�iption drugs
�' Did you lcnow there are programs to help people pay for their drugs?
� There are pt•ograrns to help people with limited resources pay for their drugs.
' These include "Extra Help" and State Pharmaceutical Assistance Programs. For
' more information, see Chapter 2, Section 7.
Are you currently getting help to pay for your drugs?
' If you are in a program that helps pay for your drugs, some information in this
Evidence of Coverage about the costs for Part D prescription drugs may not
apply to you. We send you a separate insert, called the `Bvidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known
as the "Low Income Subsidy Rider" or the "LIS Rider"), that tells you about your
drug coverage. If you don't have this insert, please call Member Services and ask
for the "LIS Rider." (Phone numbers for Member Seivices are printed on the back
cover of this booklet.)
SECTION 1 Introduction
Section 1.1 This chapter describes your coverage for Part D drugs
This chapter explains rules for using your coverage for Part D drugs. The next chapter tells
what you pay for Part D drugs (Chapter 6, What yoar pa3� fo�� yoa�r Part D prescf�iption dr�a�gs).
In addition to your coverage for Part D drugs, our plan also covet�s some drugs under the plan's
medical benefits:
• The plan covers drugs you are given during covered stays in the hospital or in a slcilled
nursing facility. Chapter 4(Medical Benefits Chart, what is covered and i-vhat you pay)
tells about the benefits and costs for drugs during a covered hospital or skilled nmsing
facility stay.
Medicare Part B also provides benefits for some drugs. Part B drugs include certain
chemotherapy drugs, certain drug injections you are given during an offce visit, and
drugs you are given at a dialysis facility. Chaptet• 4(Medical Benefrts Char�t, i��hat is
co>>ered and what yoz� pery) tells about your benefits and costs for Part B drugs.
The two examples of drugs described above are covered by the plan's medical benefits. The rest
of your prescription drugs are covered under the plan's Part D benefits.
Section 1.2 Basic rules for the plan's Part D drug coverage
The plan will generally cover your drugs as long as you follow these basic rules:
• You must have a provider (a doctor or other prescriber) write your prescription.
• You must use a network pharmacy to fill your prescription. (See Section 2, Fill yozrr
pr�escNiptions at a nehvorkpharmacy or th��ough the plan's f��zail-orde�� ser��ice.)
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• Pharmacies that supply drugs for residents of a long-term care facility. Usually, a long-
term care facility (such as a nursing home) has its own phartnacy. Residents may get
prescription drugs through the facility's pharmacy as long as it is part of our network. If
your long-term care pharmacy is not in our networlc, please contact Member Services.
Pharmacies tl�at serve the Indian Health Service / Tribal / Urban Indian Health Program
(not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska
Natives have access to these pharmacies in our networlc
Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that
require special handling, pi•ovider coordination, or education on their use. (Note: This
scenario should happen rarely.)
To locate a specialized pharmacy, look in your Provider Dir•ectory or call Member Services
(phone numbers are printed on the back cover of this booklet).
Section 2.3 Using the plan's mail-order services
For certain kinds of drugs, you can use the plan's network mail-order set•vices. Generally, the
drugs available through mail order are drugs that you take on a regular basis, for a clu'onic or
long-term medical condition. The drugs available through our plan's mail-order service are
marked as "mail-order" drugs in our Drug List.
Our plan's mail-order service allows you to order up to a 90-day supply.
To get order forms and information about filling your prescriptions by mail fi�om our preferred
mail-order pharmacy, contact Member Services (phone numbers are printed on the back cover of
this booklet). If you use a mail-order pharmacy not in the plan's networlc, your prescription will
not be covered.
Usually a mail-order pharmacy order will get to you in no more than 7 to 10 days. In the unlikely
event that there is a significant delay with your mail-order prescription drug, out• mail order
service will work with you and a network pharmacy to provide you with a temporary supply of
your mail-order prescription drug.
Section 2.4 How can you get a long-term supply of drugs?
When you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two
ways to get a long-term supply of "mail-order" drugs on our plan's Di•ug List. (Mail-order drugs
are drugs that you take on a regulat� basis, for a chronic or long-term tnedical condition.)
l. Soine retail pharinacies in our network allow you to get a long-ternl supply of
maintenance drugs. Some of these retail pharmacies may agree to accept a lower cost-
sharing amount for a long-term supply of mail-order drugs. Youi• Provider Directory tells
you which phai•macies in our network can give you a long-term supply of mail-order
drugs. You can also call Member Services for more information (phone numbers are
printed on the back cover of this booklet).
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Chapter 5: Using the plan's coverage for your Part D prescription drugs
SECTION 3
Section 3.1
Your drugs need to be on the plan's "Drug List"
The "Drug List" tells which Part D drugs are covered
The plan has a"List of Covef•ed Drugs (Fornaulary). " In this Evidence of Coverage, we call it
the "Drug List" for short.
The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.
The list must meet requirements set by Medicare. Medicare has approved the plan's Drug List.
The drugs on the Drug List are only those covered under Medicare Part D(earlier in this chapter,
Section 1.1 explains about Part D drugs).
We will generally cover a drug on the plan's Drug List as long as you follow the other coverage
rules explained in this chapter and use of the drug is a medically accepted indication. A
"medically accepted indication" is a use of the drug that is either:
• approved by the Food and Drug Administration. (That is, the Food and Drug
Administration has approved the drug for the diagnosis or condition for which it is being
prescribed.)
• -- of• -- supported by certain reference books. (These reference books are the American
Hospital Formulary Service Drug Information, the DRUGDEX Information System, and
the USPDI or its successor.)
The Drug List includes both brand name and generic clrugs
A generic drug is a prescription drug that has the same active ingredients as the brand name drug.
Generally, it works just as well as the brand name drug and usually costs less. There are generic
drug substitutes available for many brand name drugs.
What is not on the Drug List? �
The plan does not cover all prescription drugs.
• In some cases, the law does not allow any Medicare plan to cover certain types of drugs
(for more about this, see Section 7. l in this chapter).
In other cases, we have decided not to include a particular drug on our Drug List.
Section 3.2 There are different "cost-sharing tieis" for drugs on the Drug List
Every drug on the plan's Drug List is in a cost-sharing tier. In general, the higher the cost-
sharing tier, the higher your cost for the drug.
The tier structure for your plan and the amount you pay for covered prescription drugs is outlined
in the Prescription Drug Benefits Chart (also refet•red to as the Aetna Schedule of Copayments/
Coinsurance) included with this Evidence of Covei•age. Your tier structure will be one of the
following:
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SECTION 4� There are restrictions on coverage for some drugs
Section 4.1 Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team
of doctors and pharmacists developed these rules to help our members use drugs in the most
effective ways. These special rules also help control overall drug costs, which leeeps yout• drug
coverage more affordable.
In general, our rules encourage you to get a drug that works for your medical condition and is
safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher-
cost drug, the plan's rules at•e designed to encourage you and your provider to use that lower-cost
option. We also need to comply with Medicare's rules and regulations for drug coverage and cost
sharing.
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If you want us to waive the restriction for
you, you will need to use the formal appeals process and ask us to malce an eYception. We may
or may not agree to waive the restriction for you. (See Chapter 9, Section 6.2 for infortnation
about asking for exceptions.)
Section 4.2 What kinds of restrictions?
Our plan uses different types of restrictions to help our members use drugs in the most effective
ways. The sections below tell you more about the types of restrictions we use for certain drugs.
Restricting brand name drugs when a generic version is available
Generally, a"generic" drug works the same as a brand name drug and usually costs less. When a
generic version of a brand name drug is available, our network pharmacies will provide
you the generic version. We usually will not cover the brand name drug when a generic veision
is available. However, if your provider has told us the medical reason that the generic drug will
not work for you then we will cover the brand name drug. (Yout• share of the cost may be greater
for the brand name drug than for the generic drug.)
Getting plan approval in advance
For certain drugs, you or your provider need to get approval from the plan before we will agree
to cover the drug for you. This is called "prior authorization." Sometimes the requirement for
getting approval in advance helps guide appropriate use of certain drugs. If you do not get this
approval, your drug might not be covet•ed by the plan.
Trying a different drug first
This requirement encourages you to try less costly but just as effective drugs before the plan
covers another dl•ug. For eYatnple, if Drug A and Drug B treat the same tnedical condition, the
plan may t�equire you to try Drug A iirst. If Drug A does not worlc for you, the plan will then
cover Drug B. This requirement to tiy a different drug first is called "step therapy."
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into one of a number of different cost-sharing tiers. How much you pay for your
prescription depends in part on which cost-sharing tier your drug is in.
There are things you can do if your drug is not covered in the way that you'd like it to be
covered. Your options depend on what type of pt•oblem you have:
• If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn
what you can do.
• If your drug is in a cost-sharing tier that makes your cost more eYpensive than you think
it should be, go to Section 5.3 to learn what you can do.
Sectiou 5.2 What can you do if your cirug is not ou the Drug List or if the drug is
restricted in some way?
If your drug is not on the Drug List or is restricted, here are things you can do:
• You may be able to get a temporary supply of the drug (only members in certain
situations can get a temporary supply). This will give you and yout� provider time to
change to another drug or to file a request to have the drug covered.
You can change to another drug.
You can request an exception and ask the plan to cover the drug or remove restrictions
fi�om the drug.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporaly supply of a drug to you when your
drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to
talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
The change to your drug coverage must be one of the following types of changes:
• The drug you have been talcing is no longer on the plan's Drug List.
-- or -- the drug you have been taking is now resh•icted in some way (Section 4
in this chapter tells about restrictions).
2. You must be in one of the situations described below:
• For those members who were in the plan last year and aren't in a long-term
care facility:
We will cover a tempot•ary supply of your drug one time only during the first 90
days of the calendar year. This temporary supply will be for a maximum of a
31-day supply, or less if your prescription is wl•itten for fewer• days, The
prescription must be iilled at a network pharmacy.
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If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to da It
explains the procedures and deadlines that ha�e been set by Medicare to tnake sure your request
is handled promptly and fairly.
Section 5.3 What can you do if your drug is in a cost-sharing tier you thinlc is too
high?
If your drug is in a cost-sharing tier you think is too high, here are things yoLt can do:
You can change to another drug
If your drug is in a cost-sharing tier you think is too high, start by talking with your provider.
Perhaps there is a different drug in a lower cost-sharing tier that might work just as well for you.
You can call Member Services to ask for a list of covered drugs that treat the same medical
condition. This list can help your provider find a covered drug that might work for you. (Phone
nunlbets for Member Services are printed on the back cover of this booklet.)
You can ask for an exception
If your plan's tier structure has non-preferred cost-sharing tiers, you and your provider can ask
the plan to malce an exception in the cost-sharing tier for the drug so that you pay less for it. If
your provider says that you have medical reasons that justify asking us for an exception, your
provider can help you request an exception to the iule.
If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It
explains the procedures and deadlines that have been set by Medicare to make sure your request
is handled promptly and fairly.
Drugs in some of ow� cost-sharing tiers are not eligible for this type of exception. We do not
lower the cost-sharing amount for drugs in the Specialty tier.
SECTION 6 What if your coverage changes for one of your drugs?
Section 6.1 The Drug List can change during the year
Most of the changes in drug coverage happen at the beginning of each year (January 1).
However, during the year, the plan might malce many kinds of changes to the Dt•ug List. For
example, the plan might:
• Add or remove drugs from the Drug List. New drugs become available, including new
generic drugs. Perhaps the government has given approval to a new use for an existing
drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove
a drug fi•om the list because it has been found to be ineffective.
Move a drug to a higher or lower cost-sharing tier.
� Add or remove a restriction on coverage for a clrug (for more inforrnation about
restrictions to coverage, see Section 4 in this chapter).
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• Your provider will also know about this change, and can work with you to find
another drug for your condition.
SECTION 7
Section 7.1
What types of drugs are not covered by the plan?
Types of drugs we do not cover
This section tells you what kinds of prescription drugs are "excluded." This means Medicare
does not pay for these drugs.
If you get drugs that are excluded, you must pay for them yourself. We won't pay for the drugs
that are listed in this section.* (The only exception: Ifthe requested drug is found upon appeal to
be a drug that is not excluded under Part D and we should have paid for or covered it because of
your specific situation. (For information about appealing a decision we have made to not cover a
drug, go to Chapter 9, Section 6.5 in this booklet.)
Here are three general rules about drugs that Medicare drug plans will not cover under Pat•t D:
• Our plan's Par•t D drug coverage cannot cover a drug that would be covered under
Medicare Part A or Part B.
Our plan cannot cover a drug purchased outside the United States and its territories.
Our plan usually cannot cover off-label use. "Off-label use" is any use of the drug other
than those indicated on a drug's label as approved by the Food and Drug Administration.
• Generally, coverage for "off-label use" is allowed only when the use is supported
by certain reference books. These reference boolcs are the American Hospital
Formulary Service Drug Information, the DRUGDEX Information System, and
the USPDI or its successor. If the use is not supported by any of these reference
books, then oui• plan cannot cover its "off-label use."
Also, by law, these categories of drugs are not covered by Medicare drug plans:
• Non-prescription drugs (also called over-the-counter drugs)
• Drugs when used to promote fertility
• Drugs when used for the relief of cough or cold symptoms
• Drugs when used for cosmetic purposes or to promote hair growth
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations
• Drugs when used for the treattnent of sexual or et�ectile dysfunction, such as Viagra,
Cialis, Levitra, and Cavet ject
• Drugs when used for treatment of anorexia, weight loss, or weight gain
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Chapter 5: Using the plan's coverage for your Part D prescription drugs
If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we
will generally cover the cost of your prescription drugs during your stay. Once you leave the
hospital or skilled nursing facility, the plan will cover your dt�ugs as long as the drugs meet all of
our rules for coverage. See the previous parts of this section that tell about the rules for getting
drug coverage. Chapter 6(What you pay for your Part D prescription drugs) gives more
information about drug coverage and what you pay.
Please Note: When you enter, live in, or leave a skilled nutsing facility, you are entitled to a
special enrollment period. During this time period, you can switch plans or change your
coverage. (Chapter 10, Ending your r�2en�bei°ship in the plan, tells when you can leave our plan
and join a different Medicare plan.)
Section 9.2 What if you're a resident in a long-term care facility?
Usually, a long-term cat•e facility (such as a nursing home) has its own pharmacy, or a pharmacy
that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you
may get your prescription drugs through the facility's pharmacy as long as it is part of our
netwot�k.
Check yow• Provider Dit•ectory to find out if your long-term care facility's pharmacy is part of
our network. If it isn't, or if you need more information, please contact Member Services (phone
numbers are printed on the bacic cover of this booklet).
What if you're a resident in a long-term care facility and become a new member of the
plan?
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a
temporary supply of your drug during the first 90 days of your membership. The first supply
will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days.
If needed, we will cover additional i•efills during your iirst 90 days in the plan.
If you have been a member of the plan for more than 90 days and need a drug that is not on our
Drug List or if the plan has any restriction on the drug's coverage, we will cover one 31-day
supply, or less if your prescription is written for fewer days.
During the time when you are getting a temporaiy supply of a drug, you should tallc with your
provider to decide what to do when your temporaiy supply runs out. Perhaps there is a different
drug covered by the plan that might work just as well for you. Or you and your provider can ask
the plan to make an exception for you and cover the drug in the way you would like it to be
covered. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what
to do.
Section 9.3 What if you're also getting drug coverage from another
employer/union/trust retiree group plan?
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We have programs that can help our metnbers with special situations. For example, some
members have sevet•al complex medical conditions or they may need to take rnany drugs at the
same time, or they could have very high drug costs.
These programs are voluntary and fi•ee to members. A team of pharmacists and doctors
developed the programs for us. The programs can help make sure that our membets are using the
drugs that work best to treat their medical conditions and help us identify possible medication
errors.
If we have a program that fits your needs, we will automatically enroll you in the program and
send you information. If you decide not to participate, please notify us and we will withdraw you
from the program. If you have any questions about these programs, please contact Member
Services (phone numbers are printed on the back cover of this booklet).
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Chapter 6: What you pay for your Part D prescription drugs
SECTION 8 What you pay for vaccinations covered by Part D depends on how and where
you get them
Section 8.1 Our plan has separate coverage for the Part D vaccine medication
itself and for the cost of giving you the vaccination shot
Sect'ron 8.2 You may want to call us at Member Services before you get a
vaccination
SECTION 9 Do you have to pay the Part D"late enrollment penalty"?
Section 9.1 What is the Part D"late enrollment penalty"?
Section 9.2 How much is the Part D late enrollment penalty?
Section 9.3 In some situations, you can enroll late and not have to pay the
penalty
Section 9.4 What can you do if you disagree about your late enrollment
penalty?
SECTION 10 Do you have to pay an extra Part D atnount because of your income?
Section 10.1 Who pays an extra Part D amount because of incotne?
Section 10.2 How much is the extra Part D amount?
Section 10.3 What can you do if you disagree about paying an extra Part D
amount?
Section 10.4 What happens if you do not pay the extra Part D amount?
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Chapter 6: What you pay for youi• Pat�t D prescription drugs
• Chapter 5 of this booklet. Chapter 5 gives the details about your prescription drug
coverage, including rules you need to follow when you get your covered drugs. Chapter 5
also tells which types of prescription drugs are not covered by our plan.
The plan's Pt•ovidet• Directo�y. In most s'rtuations you must use a network pharmacy to
get your covered drugs (see Chapter 5 for the details). The Provider Directo��y has a list
of pharmacies in the plan's network It also tells you which pharmacies in our networlc
can give you a long-term supply of a drug (such as filling a prescription for a three-
month's supply).
SECTION 2
Section 2.1
What you pay for a drug depends on which "drug payment
stage" you are in when you get the drug
What are the drug payment stages for our plan members?
As shown in the table below, there are "drug payment stages" for your prescription drug
coverage under our plan. How much you pay for a drug depends on which of these stages you
are in at the time you get a prescription filled or refilled. Keep in mind you are always
responsible for the plan's monthly premium (if applicable) regardless of the drug payment stage.
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Chapter 6: What you pay for your Part D prescription drugs
SECTION 3 We send you reports that explain payments for your drugs
and which payment stage you are in
Section 3.1 We send you a monthly report called the "Explanation of Benefits"
(the "EOB")
Our plan keeps track of the costs of your prescription drugs and the payments you have made
when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you
when you have moved from one drug payment stage to the next. In particular•, there are two types
of costs we Iceep track of:
• We keep track of how much you have paid. This is called your "out-of-pocket" cost.
� We keep track of your "total drug costs." This is the amount you pay out-of-pocket or
others pay on your behalf plus the amount paid by the plan.
Our plan will prepare a written report called the Explanation of Benefits (it is sometimes called
the "EOB") when you have had one or more prescriptions filled through the plan during the
previous month. It includes:
• Information for that month. This report gives the payment details about the
prescriptions you have filled during the previous month. It shows the total drugs costs,
what the plan paid, and what you and others on your behalf paid.
• Totals for the year since January 1. This is called "year-to-date" information. It shows
you the total drug costs and total payments for your drugs since the year began.
Section 3.2 Help us keep our information about your drug payments up to date
To keep track of your drug costs and the payments you make for dt•ugs, we use records we get
fi�om pharmacies. Here is how you can help us keep your information correct and up to date:
• Show your membership card when you get a prescription filled. To make sure we
lcnow about the prescriptions you are filling and what you are paying, show your plan
membership card every time you get a prescription filled,
Make sure we have the information we need. There are times you may pay for
prescription drugs when we will not automatically get the information we need to
keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs,
you may give us copies of receipts for drugs that you have purchased. (If you are billed
for a covered drug, you can ask our plan to pay our share of the cost. For instructions on
how to do this, go to Chapter 7, Section 2 of this booklet.) Here are some types of
situations when you inay want to give us copies of your drug receipts to be sure we have
a complete record of what you have spent for your drugs:
• When you purchase a covered drug at a networlc pharmacy at a special price or
using a discount card that is not part of our plan's benefit.
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Chapter 6: What you pay for your Part D prescription drugs
SECTION 5
Section 5.1
During the Initial Coverage Stage, the plan pays its share of
your drug costs and you pay your share
What you pay for a drug depends on the drug and where you fill your
prescription
Dw�ing the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription
drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost
will vary depending on the drug and where you fill your prescription.
The plan has a number of Cost-Sharing Tiers
Eveiy drug on the plan's Drug List is in one of a number of cost-sharing tiers. In general, the
higher the cost-sharing tier number, the higher your cost for the drug: The tier structui•e for your
plan is listed on the Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
included with this Evic�ence of Coverage.
To find out which cost-sharing tier your drug is in, look it up in the plan's DNug List.
Your pharmacy choices
How much you pay for a drug depends on whether you get the drug fi�om:
• A retail pharmacy that is in our plan's networlc
• A pharmacy that is not in the plan's network
• The plan's mail-ordet• pharmacy
For more information about these pharmacy choices and filling your prescriptions, see Chapter 5
in this booklet and the plan's Provider Directory.
Section 5.2 Refer to your Prescription Drug Benefits Chart for a table that shows
your costs for a one-mo�ztlt supply of a drug
During the Initial Coverage Stage, your share of the cost of a covered drug will be either a
copayment or coinsurance.
• "Copayment" means that you pay a fixed amount each tiine you fill a prescription.
• "Coinsurance" tneans that you pay a percent of the total cost of the drug each time you
fill a prescription.
As shown in the table in the Prescription Drug Benefits chart (Schedule of Copayments/
Coinsurance) included with this Evidence of Coverage, the amount of the copayment or
coinsurance depends on wliich tier your drug is in. Please note:
• If your covered drug costs less than the copayment amount listed in the chart, you will
pay that lower price for the drug. You pay eithei° the full price of the drug or the
copayment amount, it�hicheve�� is loit�er•.
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Chapter 6: What you pay for your Part D prescription drugs
Coinsurance) under the section `Bnhanced Drug Benefit." To find out which drugs our plan
coveis, refer to your formulary.
The Explanation of Benefits (EOB) that we send to you will help you keep track of how much
you and the plan have spent for your drugs during the yeat�. Many people do not reach the initial
coverage limit in a year.
We will let you know if you reach the initial coverage limit amount. If you do reach this amount,
you will leave the Initial Coverage Stage and tnove on to the Coverage Gap Stage.
SECTION 6 During the Coverage Gap Stage, our plan may provide
some coverage, or you receive a discount on brand name
drugs and pay no more than 79% of the costs for generic
drugs
Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs
reach $4,750
The amount of your cost sharing during the Coverage Gap Stage is shown on the Prescription
Drug Benefits Chart (Schedule of Copayments/Coinsurance) included with this Evidence of
Coverage.
Brand drugs during the Coverage Gap Stage:
When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program
provides manufacturer discounts on brand name drugs. If your plan does not include
supplemental coverage for brand drugs you pay 47.5% of the negotiated price (excluding the
dispensing fee and vaccine administration fee, if any) for brand name drugs. Both the amount
you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs
as if you had paid them and moves you through the coverage gap. If your plan does include
suppletnental coverage for brand drugs, the discount will be applied after your plan benefits have
been determined.
Geueric drugs during the Coverage Gap Stage:
You also receive some coverage for generic drugs. If your plan does not include supplemental
coverage for generic drugs, you pay no more 79% of the cost for generic drugs and the plan pays
the rest. For generic drugs, the amount paid by the plan (21%) does not count toward your out-
of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. If
your plan does include supplemental coverage for generic drugs, you will pay the appl'rcable plan
copay for the cost sharing tier, and the amount you pay counts and moves you through the
coverage gap.
You continue paying the discounted price for brand name drugs and no more than 79% of the
costs of generic drugs until your yeat•ly out-of-pocket payments reach a maximum amount that
Medicare has set. In 2013, that amount is $4,750.
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Chapter 6: What you pay for your Part D prescription drugs
These c ments � are not incla�de�l in ,
1� �J' �
�Whenyo add up youi�out-of-pocket costs, you are �not allowed to� include any�of the� ��
� se types
of payments for prescription drugs:
• The amount you pay for your monthly premium (if applicable).
• Drugs you buy outside the United States and its territories.
• Drugs that are not covered by our plan.
• Drugs you get at an out-of-network pharmacy that do not meet the plan's requu�ements
for out-of-network coverage.
• Non-Part D drugs, including prescription drugs covered by Part A ot• Part B and other
drugs excluded from coverage by Medicare.
• Payments made by the plan for your generic drugs while in the Coverage Gap.
• Payments for your drugs that are made by group health plans including employer health
plans.
• Payments for yom� drugs that are made by certain insurance plans and government-
' funded health programs such as TRICARE and the Veteran's Administration.
!• Payments for your drugs made by a thud-party with a legal obligation to pay foi
� prescription costs (for example, Worlcers' Compensation).
Reminder: If any other organization such as the ones listed above pays part or all of your out-
of-pocket costs for drugs, you are required to tell our plan. Call Member Services to let us know
(nhone numbers are printed on the back cover of this booklet) a y_n x� r r�.,
How can you keep t�•rtck of your out-of-pocket tot�il?
• We will help you. The Explanation of Benefits (EOB) report we send to you includes the
current amount of your out-of-pocket costs (Section 3 in this chapter tells about this
report). When you reach a total of $4,750 in out-of-pocket costs for the year, this report
will tell you that you have left the Coverage Gap Stage and have moved on to the
Catastrophic Coverage Stage.
Malce sure we have the information we need. Section 3.2 tells what you can do to help
make sure that our records of what you have spent are complete and up to date.
SECTION 7 During the Catastrophic Coverage Stage, the plan pays
most of the cost for your drugs
Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this
stage for the rest of the year
Yott qualify for the Catasti•ophic Coverage Stage when youi• out-of-pocket costs have reached the
$4,750 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will
stay in this payment stage until the end of the calendar year.
GRP 12 225 D 78 PPO ESA EOC-with Rx (Y2013)
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Chapter 6: What you pay for your Part D prescription drugs
administration) during the Deductible, (if applicable) and Coverage Gap Stage of your benefit
(unless the vaccine is included in a drug tier for which plan supplemental coverage is offered).
Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at
the netwot•k pharmacy. (Whether you have this choice depends on where you live.
Some states do not allow pharmacies to administer a vaccination.)
• You will have to pay the pharmacy the amount of your coinsurance or
copayment for the vaccine itself.
Our plan will pay for the cost of giving you the vaccination shot.
Situation 2: You get the Part D vaccination at your doctor's office.
• When you get the vaccination, you will pay for the entire cost of the
vaccine and its administration.
You can then ask our plan to pay our share of the cost by using the
procedures that are described in Chapter 7 of this booklet (Asking us to
pay oz�r share of a bill you have received for• covered n�edical services or
clrugs).
You will be reimbursed the amount you paid less your normal coinsurance
or copayment for the vaccine (including administration) less any
difference between the amount the doctor charges and what we normally
pay. (If you get Extra Help, we will t�eimburse you for this difference.)
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor's
office where they give you the vaccination shot.
• You will have to pay the pharmacy the amount of your coinsurance or
copayment for the vaccine itsel%
When your doctor gives you the vaccination shot, you will pay the entu•e
cost for this service. You can then ask our plan to pay our share of the cost
by using the procedures described in Chapter 7 of this booklet.
You will be reimbursed the amount charged by the doctor for
administering the vaccine less any difference between the amount the
doctor charges and what we normally pay. (If you get E�tra Help, we will
reimbuise you for this difference.)
Section 8.2 You may want to call us at Member Services before you get a
vaccivation
The rules for coverage of vaccinations are complicated. We are hei•e to help. We recommend that
you call us first at Member Services whenever you are planning to get a vaccination. (Phone
numbers for Member Services are printed on the back cover of this booklet.)
GRP 12 225 D 80 PPO ESA EOC-with Rx (Y2013)
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Chapter 6: What you pay for your Part D prescription drugs
be 14%times $31.17. This equals $4.36, which rounds to $4.40. This amount would be
added to the monthly premium for someone with a late enrollment penalty.
There are three important things to note about this monthly late enrollment penalty:
• Fir•st, the penalty may change each year, because the average monthly premium can
change each year. If the national average premium (as determined by Medicare)
increases, your penalty will increase.
• Second, you will continue to pay a penalty every month for as long as you are enrolled
in a plan that has Medicare Part D drug beneiits.
• Third, if you are under 65 and currently receiving Medicare benefits, the late enrollment
penalty will reset when you turn 65. After age 65, your late enrollment penalty will be
based only on the months that you don't have coverage after your initial enrollment
period for aging into Medicare.
Section 9.3 In soine situations, you can enroll late and not have to pay the penalty
Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were
first eligible, sometimes you do not have to pay the late enrollment penalty.
You will not have to pay a penalty for late enrollment if you are in any of these situations:
• If you already have prescription drug coverage that is expected to pay, on average, at
least as much as Medicare's standard prescription drug coverage. Medicare calls this
"creditable drug coverage." Please note:
• Creditable coverage could include drug coverage fi•om a former employer or
union, TRICARE, or the Department of Veterans Affaii•s. Your insurer or your
human resources department will tell you each year if your drug coverage is
cyeditable coverage. This information may be sent to you in a letter or included in
a newsletter fi�om the plan. Keep this information, because you may need it if you
join a Medicare drug plan later.
• Please note: If you receive a"certificate of creditable coverage" when
your health coverage ends, it may not mean your prescription drug
coverage was creditable. The notice must state that you had "creditable"
prescription drug coverage that expected to pay as much as Medicare's
standard prescription drug plan pays.
• The following are not creditable prescription drug coverage: prescription drug
discount cards, fi•ee clinics, and drug discount websites.
For additional information about ci•editable coverage, please look in your
Medica�•e & Yoar 2013 Handbook or call Medicare at 1-800-MEDICARE (1-800-
633-4227). TTY users call 1-877-486-2048. You can call these numbers for free,
24 hours a day, 7 days a week.
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Chapter 6: What you pay for your Part D prescription drugs
The chart below shows the extra amount based on your income.
: �
� If you filecl an � If you were married � If you filed a joint � This is the monthly ��
' idual tax � but iiled a separate �� tax return and your � cost of your extra ?3
�� indiv k
�:, return and your ti tax return and your �� income in 2011 was: Part D amount (to €�
as: � income in 20ll was: R� � be paid in addition
� income in 2011 w �
�� �{ k� ry to your plan �
�� ` �� premium) ��
�� �� �� � �b
� r� ��
�� �. .... :.. ,_.._ � . ,� .� ._ �. U � .. �
�.. ��.., _. .�.� � � _ _
� . ,.
, _.. ��� � ._m. , E
�„�. ..�.._ m.,o.�ro .., w. , . . . r
� Equal�to or �less than Equal to oi- less than Equal to or less tihan �� �
$85,000 $85,000 $170,000 �
� ��
� . � � _. _ �,w ._. _ , , _ _�_�_.. _ . �_ ,
,�� .. �m r �,
��
�� � �� _ .. . , v:., � , ,_ _,.,- . . � �Greater than � � �
Greaterthan�$85,000
� and less than or equal $170,000 and less [
$11.60;
� to $107,000 than or equal to '
� $214,000 �
�
� _ � ,. � .._
i, ���, _ _.. ._ .. _ �. _ _ ._ .� _.� _ w_
� � , . �,,. � �
,.� �. __.
�_� _ . ,..-�.< u � � , _
�... . _ , _, �
� � � Greater than � �
° Greater than
i $107,000 and less $214,000 and less $29.90 4
� than or equal to �
than or equal to
� $160,000 $320,000 ;
---o . r �,-x . u, �.� _ ._. .. _ -, w-,:
�._ Y. _ H -.- � , - ��, _�.., . .._ _ -,_ ; -., . �
��.,, m ,._ _ �
� Greater��than � Greater than $85,000 Greatei than
� $160,000 and less and less than or equal $320,000 and less $48.30 �
� than or equal to to $129,000 than or equal to .,,
� $214,000 $428,000 =
� �___ _.�.� � �
��� n. . _ � _..
��� _ ..___.._
_ _�
� "�'
� .v x--:,. �w - �
�Greater than Greater than Greater than
? $214,000 $129,000 $428,000 $66.60 �
� C�
� ��
t,� .., :. �..,.. . ,..�. ,.
� . . , . .. , .r. . .,, � .... . , � , „� . _
�, , , ; , _ p .,. , _ , .. , � , , o .: � , � € �
4�� . , . � � �� -
Sectiou 10.3 What can you do if you disagree about paying an extra Part D
amouvt?
If you disagree about paying an extra amount because of your income, you can ask Social
Security to review the decision. To find out tnor•e about how to do this, contact Social Security at
1-800-772-1213 (TTY 1-800-325-0778).
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Chapter 7: Asking us to pay our share of a bill you have received fot• covered medical services or
drugs
Chapter 7 Askin� us to pav our share of a bill vou have received for covered
medical services or dru�s
SECTION 1 Situations in which you should ask us to pay our share of the cost of your
covered services or drugs
Section 1.1 If you pay our plan's share of the cost of your covered services or
drugs, or if you receive a bill, you can ask us for payment
SECTION 2 How to ask us to pay you back or to pay a bill you have received
Section 2.1 How and where to send us your request for payment
SECTION 3 We will consider your request for payment and say yes or no
Section 3.1 We check to see whether we should cover the service or drug and
how much we owe
Section 3.2 If we tell you that we will not pay for all or part of the medical care
or drug, you can make an appeal
SECTION 4 Other situations in which you should save your receipts and send copies to us
Section 4.1 In some cases, you should send copies of your receipts to us to
help us track your out-of-pocket drug costs
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Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or
drugs
2. When a network provider sends you a bill you thinlc you should not pay
Network providers should always bill the plan directly, and ask you only for your share
ofthe cost. But sometimes they make mistakes, and ask you to pay more than yout� shai•e.
• You only have to pay your cost-sharing amount when you get services covered by
our plan. We do not allow providers to add additional separate charges, called
"balance billing." This protection (that you never pay more than your cost-sharing
amount) applies even if we pay the provider less than the provider charges for a
service and even if there is a dispute and we don't pay certain provider charges.
For more information about "balance billing," go to Chapter 4, Section 1.3.
• Whenever you get a bill fi•om a network provider that you thinlc is more than you
should pay, send us the bill. We will contact the provider directly and resolve the
billing problem.
• If you have already paid a bill to a network provider, but you feel that you paid
too much, send us the bill along with documentation of any payment you have
made and ask us to pay you back the difference between the amount you paid and
the amount you owed under the plan.
3. If you are retroactively enrolled in our plan.
Sometimes a person's enrollment in the plan is retroactive. (Retroactive means that the
iirst day of their enrollment has already passed. The ent•ollment date may even have
occurred last year.)
If you were rett•oactively enrolled in our plan and you paid out-of-pocket for any of your
covered services or drugs after your enrollment date, you can aslc us to pay you back for
our share of the costs. You will need to submit paperwork for us to handle the
reimbursement.
• Please call Member Services for additional information about how to ask us to
pay you back and deadlines for making your request. (Phone numbers for
Member Services are printed on the back cover of this booklet.)
4. When you use an out-of-network pharmacy to get a pi'escription �lled
If you go to an out-of-networlc pharmacy and try to use yotu� membership card to fill a
prescription, the pharmacy may not be able to submit the claim du•ectly to us. When that
happens, you will have to pay the full cost of your prescription. (We cover prescriptions
iilled at out-of-networlc pharmacies only in a few special situations. Please go to Chapter
5, Sec. 3.5 to learn more.)
• Save your receipt and send a copy to us when you ask us to pay you back for our
share of the cost.
5. Wheu you pay the full cost for a prescription because you don't have your plan
membership card with you
If you do not have your plan menlbership card with you, you can ask the pharmacy to call
the plan or to look up your plan enrollment information. However, if the pharmacy
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Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or
drugs
For medical claims, mail yout• request for payment together with any bills or receipts to us at the
address below.
Aetna Life Insurance Company
P.O. Box 981106
El Paso, TX 79998-1106
Contact Member Services if you have any questions (phone numbers are printed on the back
cover of this booklet). If you don't know what you should have paid, or you receive bills and you
don't know what to do about those bills, we can help. You can also call if you want to give us
more information about a request for payment you have already sent to us.
SECTION 3
Sectiou 3.1
We will consider your request for payment and say yes or
no
We check to see whether we should cover the service or drug and how
much we owe
When we receive your request for payment, we will let you know if we need any additional
information fi•om you. Otherwise, we will consider your request and make a coverage decision.
• If we decide that the medical care ot• drug is covered and you followed all the rules for
getting the care or drug, we will pay for our share of the cost. If you have already paid for
the service or drug, we will mail your reimbursement of our share of the cost to you. If
you have not paid for the service or drug yet, we will mail the payment directly to the
provider. (Chapter 3 explains the rules you need to follow for getting your medical
services covered. Chapter 5 explains the rules you need to follow for getting your Part D
prescription drugs covered.)
If we decide that the medical care or drug is not covered, or you did not follow all the
rules, we will not pay for our share of the cost. Instead, we will send you a letter that
explains the reasons why we are not sending the payment you have requested and your
rights to appeal that decision.
Section 3.2 If we tell you that we will not pay for all or part of the ineclical care or
drug, you can make an appeal
If you think we have made a mistake in turning down your request for payment or you don't
agree with the amount we are paying, you can make an appeaL If you make an appeal, it means
you are asking us to change the decision we made when we turned down your request for
paytnent.
Fol• the details on how to make this appeal, go to Chapter 9 of this booklet (I�Tjhcrt to do if yo2�
hcrve a proble»1 of° complaint (coverage decisions, appeal.r, complaints)). The appeals process is
a formal process with detailed procedures and important deadlines. If making an appeal is new to
yott, you will find it helpful to start by reading Section 4 of Chapter 9. Section 4 is an
introductory section that eaplains the process for coverage decisions and appeals and gives
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Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or
drugs
• Save your f•eceipt and send a copy to us so that we can have your out-of-pocket
expenses count toward qualifying you for the Catastrophic Coverage Stage.
Please note: Because you are getting your drug through the patient assistance
program and not tht•ough the plan's benefits, we will not pay for any share of
these drug costs. But sending a copy of the receipt allows us to calculate your out-
of-pocket costs correctly and may help you qualify for the Catastrophic Coverage
Stage more quicicly.
Since you are not asking for payment in the two cases described above, these situations are not
considered coverage decisions. Therefore, you cannot malce an appeal if you disagree with our
decision.
GRP 12 225 D 92 PPO ESA EOGwith Rx (Y2013)
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Chaptei• 8: Your rights ai�d responsibilities
SECTION 1 Our plan must honor your rights as a member of the plan
Section l.l We inust provide information in a way that works for you (in
languages other than English, in Braille, in large print, or other
alternate formats, etc.)
Debemos proveer informacion en un formato que sea adecuado para
usted (en idiomas distintos del utilizado en este folleto, en braille, en
letra grande u otros formatos alternativos, etc.)
To get information fi•om us in a way that works for you, please call Member Services (phone
numbers are printed on the back cover of this booklet).
Our plan has people and free language interpreter services available to answer questions fi•om
non-English speaking members. We can also give you information in Braille, in large print, or
other alternate formats if you need it. If you are eligible for Medicare because of a disability, we
are required to give you information about the plan's benefits that is accessible and appropriate
for you.
If you ha�e any trouble getting information fi•om our plan because of problems related to
language or a disability, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours
a day, 7 days a week, and tell them that you want to file a complaint. TTY users call 1-877-486-
2048.
Section 1.2 We must treat you with fairness and respect at all times
Our plan must obey laws that protect you from discrimination or unfair treatment. We do not
discriminate based on a person's t•ace, ethnicity, natronal origin, religion, gender, age, mental or
physical disability, health status, claims experience, medical history, genetic information,
evidence of insurability, or geographic location within the service area.
If you want mo�•e infortnation oj• have concerns about discrimination oi• un�air treatment, please
call the Department of Health and Human Services' Office for Civil Rights 1-800-368-1019
(TTY 1-800-537-7697) or your local Office for Civil Rights.
If you have a disability and need help with access to care, please call us at Member Services
(phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a
problem with wheelchair access, Member Services can help.
Sectiou 1.3 We must ensure that you get timely access to your covered services
and drugs
You have the right to choose a provider for your care.
As a plan member, you have the right to get appointments and covered services from your
providers 1-t�ithin a r•easonable an�zount of time. This includes the right to get timely seivices fi�om
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Chapter 8: Your i•ights and responsibilities
You have the right to lcnow how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of yom� personal health information, please
call Member Services (phone numbers are printed on the back cover of this booklet).
Section 1.5 We must give you information about the plan, its network of
providers, anci your covered services
As a member of our plan, you have the right to get several lcinds of information fi•om us. (As
explained above in Section 1.1, you have the right to get information from us in a way that works
for you. This includes getting the information in languages other than English and in large print
or other alternate formats.)
If you want any of the following lcinds of information, please call Member Services (phone
numbers are printed on the bacic cover of this booklet):
• Information about our plan. This includes, for example, information about the plan's
financial condition. It also includes information about the number of appeals made by
members and the plan's performance ratings, including how it has been rated by plan
members and how it compares to other Medicare health plans.
Information about our network providers including our network pharmacies.
• For example, you have the right to get information fi•om us about the
qualifications of the providers and pharmacies in our network and how we pay the
providers in our network.
Fot� a list of the providers and pharmacies in the plan's network, see the Pr�ovide�°
Dir�ectory.
For more detailed information about our providers or pharmacies, you can call
Member Services (phone numbers are printed on the back cover of this booklet)
or visit our website at http://www.aetnaretireeplans.com.
Information about your coverage and rules you must follow in using your coverage.
• In Chapters 3 and 4 of this booklet, we explain what medical services are covered
for you, any restrictions to your coverage, and what rules you must follow to get
your covered medical services.
To get the details on your Part D prescription drug coverage, see Chapters 5 and 6
of this boolclet plus the plan's List of Cover�ed Dr�i�gs (Formatla�y). These chapters,
together with the List of Covered Dr•ugs (For�mrlar�), tell you what drugs ai•e
covered and explain the rules you must follow and the restrictions to your
coverage for certain drugs.
If you have questions about the rules or restrictions, please call Member Services
(phone numbers are printed on the bacic cover of this booklet).
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Chaptel• 8: Your rights and responsibilities
• To receive an explanation if you are denied coverage for care. You have the right.to
receive an explanation fi•otn us if a provider has denied care that you believe you should
receive. To receive this explanation, you will ueed to ask us for a coverage decision.
Chapter 9 of this boolclet tells how to ask the plan for a coverage decision.
You have the right to give instructions about what is to be done if you are not aUle to make
meclical decisions for yourself
Sornetimes people become unable to make health care decisions for themselves due to accidents
or set�ious illness. You have the right to say what you want to happen if you are in this situation.
This means that, if you ��ant to, you can:
• Fill out a written form to give someone the legal authority to make medical decisions
for you if you ever become unable to make decisions for yourself.
Give your doctors written instructions about how you want them to handle your
medical care if you become unable to malce decis'rons for youtself.
The legal docttments that you can use to give your directions in advance in these situations are
called "advance directives." There are different types of advance directives and different names
for them. Documents called "living will" and "power of attoruey for health care" are examples
of advance directives.
If you want to use an "advance directive" to give your instructions, here is what to do:
• Get the form. If you want to have an advance directive, you can get a form from your
lawyet�, from a social worker, or from some office supply stores. You can sometimes get
advance directive forms fi�om organizations that give people information about Medicare.
You can also contact Member Services to ask for the forms (phone numbets are printed
on the back cover of this booklet).
Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a
legal document. You should consider ha�ing a lawyer help you prepare it.
Give copies to appropriate people. You should give a copy of the form to your doctor
and to the person you name on the form as the one to make decisions for you if you can't.
You may want to give copies to close friends or family members as well. Be sure to keep
a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance
directive, take a copy with you to the hospital.
• If you are admitted to the hospital, they will aslc you whether you have signed an advance
directive form and whether you have it with you.
If you have not signed an advance directive form, the hospital has forms available and
will ask if you want to sign one.
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Chapter 8: Your rights and responsibilities
Section 19 How to get more information about your rights
There are several places where you can get more information about your rights:
• You can call Member Services (phone numbers are printed on the back cover of this
booklet).
• You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.
- You can contact Medicare.
• You can visit the Medicare website to read or download the publication "Your
Medicare Rights & Protections." (The publication is available at:
http://www.medicare.gov/Publications/Pubs/pdf/ 10112.pdf.)
Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. TTY useis should call 1-877-486-2048.
SECTION 2 You have some responsibilities as a member of the plan
Section 2.1 What are your responsibilities?
Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services (phone numbers are printed on the back cover of this booklet).
We're heye to help.
• Get familiar witli youf• cover�ed ser•vices and tlae rules you ►nust follow to get tlaese
cove��ecl se�vices. Use this Evidence of Coverage booklet to learn 1-nhat is covered for you
and the rzales yozr need to follotiv to get yozr�° cove�°ed se�-vices.
• Chaptet•s 3 and 4 give the details about your niedical services, including what is
covered, what is not covered, rules to follow, and what you pay.
Chapters 5 and 6 give the details about your coverage for Part D prescription
drugs.
• If you have u►ry ot/rer )zealtlz i�tsurance cover�cge os� py�escr�iption drug coverage ifi
additiort to our plafz, you at�e ��equif•ed to tell us. Plecrse call Member Seyvices to let z�s
I�r�ow (pl�one numbe�°s are pr�inted on the bacic cove�• of this booklet).
• We ate required to follow rules set by Medicare to make sut•e that you are using
all of youi• covei•age in combination when you get your covered services from our
plan. This is called "coordination of benefits" because it involves coordinating
the health and drug benefits you get fi•om our plan with any other health and drug
beneiits available to you. We'll help you with it. (For more information about
coordination of benefits, go to Chapter 1, Section 7.)
• Tell yoat�� cloctot� a�id otli�er 1lealtlz cai�e pr�oviders tli�d yoa� rn�e enrollerl in� ouf• plan.
Sho�>> yoa��° plcm »�ef�aber�sl�ip ca�°c� i��l�enevef• you get yoi�r r��edical care or� Part D
pr�esc�°iption drugs.
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Chapter 8: Your rights and responsibilities
• Tell us if you niove. If you are going to move, it's important to tell us right aivcry. Call
Member Services (phone nuf��zbers are �r•inted on the bcrck cove�• of this booklet).
• If you move ouiside of our plan service area, you cannot remain a member of
our plan. (Chapter 1 tells about our service area.) We can help you figure out
whether you are moving outside our service area. If you are leaving our service
area, you will have a Special Enrollment Period when you can join any Medicare
plan available in your new area. We can let you know if we ha�e a plan in your
new area.
If you move within our service area, we still need to know so we can lceep your
membership record up to date and know how to contact you.
Call Member Ser•vices fot� Izelp if you ltave questions or cotzce��ns. We al,so welcon�re any
si�ggesiions yoa� may have for� i���proving oatr• plan.
• Phone numbers and calling hours for Member Services at�e printed on the bacic
cover of this boolclet.
For more information on how to reach us, including our mailing address, please
see Chapter 2.
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Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
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Section 6.4
Section 6.5
Section 6.6
Step-by-step: How to ask for a coverage decision, including an
exception
Step-by-step: How to make a Level 1 Appeal (how to ask for a
review of a coverage decision made by our plan)
Step-by-step: How to make a Level 2 Appeal
SECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the doctor
is discharging you too soon
Section 7.1 During your inpatient hospital stay, you will get a written notice
fi•om Medicare that tells about your rights
Section 7.2 Step-by-step: How to make a Level 1 Appeal to change your
hospital discharge date
Section 7.3 Step-by-step: How to make a Level 2 Appeal to change your
hospital discharge date
Section 7.4 What if you miss the deadline for making your Level 1 Appeal?
SECTION S How to ask us to keep covering certain medical services if you think your
coverage is ending too soon
Section 8.1 This section is about three services onl : Home health care, skilled
nursing facility care, and Comprehensive Outpatient Rehabilitation
Facility (CORF) services
Section 8.2 We will tell you in advance when your coverage will be ending
Section 8.3 Step-by-step: How to make a Level 1 Appeal to have our plan
cover your care for a longer time
Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan
cover your care for a longer time
Section 8.5 What if you miss the deadline for making your Level 1 Appeal?
SECTION 9 Taking your appeal to Level 3 and beyond
Section 9.1 Levels of Appeal 3, 4, and 5 for Medical Service Appeals
Section 9.2 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals
MAKING COMPLAINTS
SECTION 10 How to malce a complaint about quality of care, waiting times, customer
service, or other concerns
Section 10.1 What kinds of problenls are handled by the complaint process?
Section 10.2 The formal naine for "making a cotnplaint" is "filing a grievance"
Section 10.3 Step-by-step: Making a complaint
Section l 0.4 You can also make complaints about quality of care to the Quality
Improvement Organization
Section 10.5 You can also tell Medicare about youi• complaint
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complaints)
SECTION 2
Sectiou 2.1
You can get help from government organizations that are
not connected with us
Where to get more information and personalized assistance
Sometimes it can be confusing to start or follow through the process for dealing with a problem.
This can be especially true if you do not feel well or have limited energy. Other times, you may
not have the lcnowledge you need to take the next step.
Get help from an independent goverument organization
We are always available to help you. But in some situations you may also want help ot• guidance
from someone who is not connected with us. You can always contact your State Health
Insurance Assistance Program (SHIP). This government program has trained counselors in
evely state. The program is not connected with us or with any insurance company or health plan.
The counselors at this program can help you understand which process you should use to handle
a problem you are having. They can also answer your questions, give you more information, and
offer guidance on what to do.
The services of SHIP counselors are fi�ee. You will find phone numbers in Addendum A of this
booklet.
You can also get help and information from Medicare
For more information and help in handling a problem, you can also contact Medicare. Here are
two ways to get information d'u�ectly from Medicare:
• You can call 1-S00-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY
users should call 1-877-486-2048.
You can visit the Medicare website (http://www.medicare.gov).
SECTION 3
Section 3.1
To deal with your problem, which process should you use?
Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints?
If you have a problem or concern, you only need to read the parts of this chapter that apply to
your sitttation. The guide that follows will help.
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Malung an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the
decision. An appeal is a formal way of asking us to review and change a coverage decision we
have nlade.
When you make an appeal, we review the coverage decision we have made to checic to see if we
were following all of the rules properly. Your appeal is handled by different reviewers than those
who made the original unfavorable decision. When we have completed the review, we give you
our decision.
If we say no to all or part of your Level 1 Appeal, you can go on to a Leve12 AppeaL The Level
2 Appeal is conducted by an independent organization that is not connected to us. (In some
situations, your case will be automatically sent to the independent organization for a Level 2
Appeal. If this happens, we will let you know. In other situations, you will need to ask for a
Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be
able to continue through several more levels of appeal.
Section 4.2 How to get help when you are asking for a coverage decision or
making an appeal
Would you like some help? Here at•e resources you may wish to use if you decide to ask for any
kind of coverage decision or appeal a decision:
• You can call us at Member Services (phone numbers are printed on the bacic cover of
this booklet).
To get free help from an independent organization that is not connected with our plan,
contact your State Health Insurance Assistance Program (see Section 2 of this chapter).
� Your doctor or other provider can make a request for you. For medical care, a doctor
can make a request for you. Your doctor can request a coverage decision or a Level 1
appeal on your behalf. If your appeal is denied at Level 1, it will be automatically
forwarded to Level 2. To request any Appeal after Level 2, your doctor must be
appointed as your representative. For Part D prescription drugs, yom� doctor or other
prescr•iber can request a coverage determination or a Level 1 or 2 appeal on your behalf.
To request any appeal after Level 2, your doctor or other prescriber must be appointed as
your representative.
• You can aslc someone to act on your behalf. If you want to, you can name another
person to act for you as your "representative" to aslc for a coverage decision or make an
appeal.
• There may be someone who is ah•eady legally authorized to act as your
representative under state law.
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SECTION 5 Your medical care: How to ask for a coverage decision or
make an appeal
�` Have you read Section 4 of this chapter (A guide to "the bcrsics " of coverage decisions
and appeals)? If not, you may want to read it before you start this section.
Section 5.1 This section tells what to cio if you have problems getting coverage for
medical care or if you want us to pay you back for our share of the
cost of your care
This section is about your benefits for medical care and services (but does not cover Part D
drugs, please see Section 6 for Part D drug appeals). These benefits are described in the Medical
Benefits Chart (Summaiy of Copayments/Coinsurance) included with this Evidence of Coverage.
To keep things simple, we generally refer to "medical care coverage" or "medical care" in the
rest of this section, instead of repeating "medical care or treatment or services" every time.
This section tells what you can do if you are in any of the five following situations:
l. You are not getting certain medical care you want, and you believe that this care is
covered by our plan.
2. Our plan will not approve the medical care your doctor or other medical provider wants
to give you, and you believe that this care is covered by the plan.
3. You have received medical care or services that you believe should be cover•ed by the
plan, but we have said we will not pay for this care.
4. You have received and paid for medical care or services that you believe should be
covered by the plan, and you want to ask our plan to reimburse you for this care.
5. You are being told that coverage for certain nledical care you have been getting that we
previously approved will be reduced ol• stopped, and you believe that reducing or
stopping this care could harm your health.
• NOTE: If the coverage that will be stopped is for hospital care, home health
care, slalled nursing facility car•e, or Comprehensive Outpatient
Rehabilitation Facility (CORF) sei•vices, you need to read a separate section of
this chapter because special rules apply to these types of care. Here's what to read
in those situations:
• Chapter 9, Section 7: Hoi�>> to ask us to cove�° a lon�ger• inpatient hospital
stcry if you think the doctor• is discl�arging yo�ar too soon.
• Chapter 9, Section 8: Hoiv to ask iss to keep cove�°ing certain medical
services if yoat thi��k yoatr� cove�°crge is ending too soon. This section is
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Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
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For the details on how to contact us, go to Chapter 2, Section 1 and loolc for the section
called, How to contact us tivhen yoz� are asking for• a covef°age decision about you�•
medical car�e.
Generally ti�ve use the starrdard deadlines for giving you oa�r decision�
When we give you our decision, we will use the "standard" deadlines unless we have agreed to
use the "fast" deadlines. A standard coverage decision means we will give you an answer
within 14 days after we receive your request.
• However, we can take up to 14 more calendar days if you ask for more time, or if we
need information (such as medical records from out-of-network providers) that may
benefit you. If we decide to take extra days to make the decision, we will tell you in
wt•iting.
If you believe we should not take eYtra days, you can file a"fast complaint" about our
decision to take extra days. When you file a fast complaint, we will give you an answer to
your complaint within 24 houts. (The process for making a complaint is different fi�onl
the process for coverage decisions and appeals. For more information about the process
for making complaints, including fast complaints, see Section 10 of this chapter.)
If your health reqziires it, ask �ars to give you a` fast coverage decision "
• A fast coverage clecision means we will answer within 72 hours.
• However, we can take up to 14 more calendar days if we find that some
information that may benefit you is missing (such as medical records fi•om out-of-
network providers), or if you need time to get information to us for the review. If
we decide to take extra days, we will tell you in writing.
If you believe we should not take extra days, you can file a"fast complaint" about
our decision to talce extra days. (For more information about the process for
making complaints, including fast complaints, see Section 10 of this chapter.) We
will call you as soon as we malce the decision.
To get a fast coverage decision, you must meet two requirements:
• You can get a fast coverage decision only if you are asking for coverage for
medical care you have not yet r•eceivec�. (You cannot get a fast coverage decision
if your request is about payment for medical care you have already received.)
• You can get a fast covet•age decisioil of�ly if using the standard deadlines could
caarse sei^ious hcn•�n� to you�� henith or� huNt youf� abilit�� to firnction.
If your doctor tells us that your health requires a"fast coverage decision," we will
automatically agree to give you a fast coverage decision.
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Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
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• We can take up to 14 more calendar days ("an extended time period") under
certain circumstances. If we decide to talce extra days to make the coverage
decision, we will tell you in writing.
• If you believe we should not take extra days, you can file a"fast complaint" about
our decision to take extra days. When you fle a fast complaint, we will give you
an answer to your complaint within 24 hours. (For more info►•mation about the
process for making complaints, including fast complaints, see Section 10 of this
chapter.)
• If we do not give you our answer within 14 days (or if there is an extended time
period, by the end of that period), you have the right to appeal. Section 5.3 below
tells how to make an appeal.
If our answer is yes to part or all of what you requested, we must authorize or provide
the coverage we have agreed to provide within 14 days after we received your request. If
we extended the time needed to make our coverage decision, we will provide the
coverage by the end of that extended period.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no.
Step 3: If we say no to your request for coverage for medical care, you decide if you want to
make an appeal.
• If we say no, you have the right to ask us to reconsider — and perhaps change — this
decision by making an appeal. Malcing an appeal means making another try to get the
medical care coverage you want.
If you decide to make an appeal, it means you are going on to Level 1 of the appeals
process (see Section 5.3 below).
Section 5.3 Step-by-step: How to make a Level 1 Appeal (how to ask for a review
of a medical care coverage decision made by our plan)
Legal An appeal to the plan about a medical care coverage decision is called a plan
Terms "reconsideration."
Step 1; You contact us ancl malce your appeaL If your health requires a quick response, you
must ask for a"fast appeal."
What to do
• To start your appeal, you, your doctor, or your representative, must contact us. For
details on how to reach us for any purpose related to your appeal, go to Chapter 2,
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The requirements and procedures for getting a"fast appeal" are the same as those for
getting a"fast coverage decision." To aslc for a fast appeal, follow the instructions for
asking for a fast coverage decision. (These instructions are given earlier in this section.)
If your doctor tells us that your health requires a"fast appeal," we will give you a fast
appeal.
Step 2: We consider your appeal and we give you our answer.
• When our plan is reviewing your appeal, we take another careful look at all of the
information about your request fot• coverage of inedical care. We check to see if we were
following all the rules when we said no to your request.
We will gather more infot•mation if we need it. We may contact you or your doctor to get
more information.
Deadlines for a `fast" uppeal
• When we ar•e using the
after we receive your
re uires us to do so
fast deadlines, we must give you our answer withiu 72 hours
appeal. We will give you our answer sooner if your health
q •
• However, if you ask for more time, or if we need to gather mot•e information that
may benefit you, we can take up to 14 more calendar days. If we decide to take
extra days to nlake the decision, we will tell you in writing.
If we do not give you an answer w'rthin 72 hours (or by the end of the eYtended
time period if we took extra days), we are required to automatically send your
request on to Level 2 of the appeals process, where it will be reviewed by an
independent organization. Later in this section, we tell you about this organization
and explain what happens at Leve12 of the appeals process.
If our answer is yes to part or all of what you requested, we must authorize or provide
the coverage we have agreed to provide within 72 hours after we receive your appeal.
If our answer is no to part or all of what you requested, we will send you a written
denial notice informing you that we ha�e automatically sent your appeal to the
Independent Review Organization for a Leve12 Appeal.
Deadlines for a "standar•�P' appeal
• If we are using the standard deadlines, we must give you our answer within 30 calendar
days after we receive your appeal if your appeal is about coverage for services you have
not yet received. We will give you our decision sooner if your health condition requires
us to.
• However, if you ask for more time, or if we need to gather more information that
may benefit you, we can take up to 14 more calendar days.
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You have a right to give the Independent Review Organization additional information to
support your appeal.
Reviewers at the Independent Review Organization will take a carefiil look at all of the
information related to your appeal.
If you had a` fast" appeal at Level 1, yoz� tinill also have a`fiist" appeul at Level 2
• If you had a fast appeal to our plan at Level 1, you will automatically receive a fast
appeal at Level 2. The review organization must give you an answer to your Level 2
Appeal within 72 hours of when it receives your appeal.
However, if the Independent Review Organization needs to gather more information that
may benefit you, it can talce up to 14 more calendar days.
If you had a"stanc�ard " appeal at Level 1, you will also hcn�e a"sta�itla�•�l" appeal at Level 2
• If you had a standard appeal to our plan at Level 1, you will autotnatically receive a
standard appeal at Level 2. The review organization must give you an answer to your
Level 2 Appeal within 30 calendar days of when it receives your appeal.
However, if the Independent Review Organization needs to gather more information that
may benefit you, it can take up to 14 more calendar days.
Step 2: The Independent Review Organization gives you their answer.
The Independent Review Ot�ganization will tell you its decision in writing and explain the
reasons for it.
• If the review organization says yes to part or all of what you requested, we must
authorize the medical care coverage within 72 hours or provide the setvice within 14
calendar days after we receive the decision fi•om the review organization.
If this organization says no to part or all of your appeal, it means they agree with us
that your request (or part of your request) for covei•age for medical care should not be
approved. (This is called "upholding the decision." It is also called "turning down your
appeal.")
• The written notice you get fi•om the Independent Review Organization will tell
you the dollar amount that must be in dispute to continue with the appeals
process. For example, to continue and make another appeal at Level 3, the dollar
value of the medical care coverage you are requesting must meet a cei•tain
minimum. If the dollai• value of the coverage you ai•e requesting is too low, you
cannot make another appeal, which means that the decision at Leve12 is final.
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Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
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What if you ask for payment and we say that we will not pay?
If you do not agree with our decision to turn you down, you can make an appeal. If you make
an appeal, it means you are asking us to change the coverage decision we made when we turned
down your request for payment.
To make this appeal, follow the process for appeals that we describe in part 5.3 of this
section. Go to this part for step-by-step instructions. When you are following these instructions,
please note:
• If you make an appeal for reitnbursement, we tnust give you our answer within 60
calendar days after we receive yout• appeal. (If you are asking us to pay you bacic for
medical care you have ah�eady received and paid for yourself, you are not allowed to ask
for a fast appeal.)
If the Independent Review Organization reverses our decision to deny payment, we must
send the payment you have requested to you or to the provider within 30 calendar days. If
the answer to your appeal is yes at any stage of the appeals process after Level 2, we
must send the payment you requested to you or to the provider within 60 calendar days.
SECTION 6 Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal
� Have you read Section 4 of this chapter (A gz�ide to "the basics" of coverage
clecisions and appeals)? If not, you may want to read it before you start this section.
Section 6.1 This section tells you what to do if you have problems getting a Part D
drug or you want us to pay you back for a Part D drug
Your benefits as a member of our plan include coverage for many prescription drugs. Please
refer to our plan's List of Covered Df•ugs (Forr�zulary). To be cover•ed, the drug must be used for
a medically accepted indication. (A "medically accepted indication" is a use of the drug that is
either approved by the Food and Drug Administration or supported by certain reference books.
See Chapter 5, Section 4 for more information about a medically accepted indication.)
• This section is about your Part D drugs only. To keep things simple, we generally say
"drug" in the rest of this section, instead of repeating "covered outpatient prescription
drug" or "Part D drug" eveiy time.
For details about what we mean by Part D drugs, the List of Covered Drugs (For�n�ulaiy),
i•ules and restrictions on coverage, and cost information, see Chapter 5(Usi�7g ozir plan's
cover�age fo�� yoair• Payt D pr•esc��iptzon dri�gs) and Chapter 6(What you pay fo�° yoi�r� Par�t
D pf^escf•iption d��ztgs).
Part D coverage decisions and appeals
As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your
benefits and coverage or about the amount we will pay foi• your drugs.
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Chapter 9: What to do if you have a problem or complaint (covei•age decisions, appeals,
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Which of these situations are you in?
coverage decision
Start with Section 6.2 �
of this chapter. � Skip ahead to Section
I � 6.4 of this chapter.
�
Section 6.2 What is an exception?
6.4 of this chapter.
Skip ahead to Section
6.5 of this chapter.
If a drug is not covered in the way you would like it to be covered, you can ask us to make an
"exception." An exception is a type of coverage decision. Similar to other types of coverage
decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical
reasons why you need the exception approved. We will then consider your request. Here are
three examples of exceptions that you or your doctor or other prescriber can aslc us to make:
1. Coveriug a Part D drug for you that is not on our List of Covered D��ugs
(Formulafy). (We call it the "Drug List" for short.)
Legal Asking for covet�age of a drug that is not on the Drug List is sometimes called
Terms asking for a"formulary exception."
• If we agree to make an exception and cover a drug that is not on the Drug List,
you will need to pay the cost-sharing amount that applies to drugs in the
exceptions cost-sharing tier. You cannot ask for an exception to the copayment or
coinsurance amount we require you to pay for the drug.
2. Removing a restriction ou our coverage for a covered drug. There are exti•a j'ules or
rest�•ictions that apply to certain drugs on our List of Covef�ec� DNugs (Formz�lary) (for
more information, go to Chapter 5 and look for Section 5).
Legal Asking for removal of a restriction on coverage for a drug is sometitnes called
Terms aslcing for a"formulary exception."
The e�tra rules and restrictions on covei•age for certain di•ugs include:
• Getti��g plczn� a�p��oval zn aclva»ce before we will agree to cover the drug
for you. (This is sometimes called "prior authorization.")
Being requi��ed to t�}� a clifferent drarg fi��st before we will agree to covei•
the drug you are asking for. (This is sometimes called "step therapy.")
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Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
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• If we say no to your request for an exception, you can ask for a review of our decision by
malting an appeal. Section 6.5 tells how to make an appeal if we say no.
The next section tells you how to ask for a coverage decision, including an exception.
Section 6.4 Step-by-step: How to aslz for a coverage decision, including an
exception
Sten l: You ask us to make a coverage decision about the drug(s) or payment you need. If
your health requires a quick t•esponse, you must ask us to malee a"fast coverage decision." You
cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you
already bought.
What to do
• Request the type of coverage decision you want. Start by calling, writing, or faxing us
to make your request. You, your representative, or yout• doctor (or other prescriber) can
do this. For the details, go to Chapter 2, Section 1 and look for the section called, Ho�v to
contact us tinhen yo�at are asking for a coverage decision avout your Part D�rescYiption
dra�gs. Or if you are aslcing us to pay you bacic for a drug, go to the section called, Where
to send a request that crsks us to pay for our� shar�e of the cost for n�edicczl care or a drug
you I�ave Neceived.
• You or your doctor or someone else who is acting on your behalf can ask for a
coverage decision.
someone else to �
behalf.
Section 4 of this chapter tells how you can give written peimission to
ct as your representative. You can also have a lawyer act on yom�
If you want to ask us to pay you back for a drug, start by reading Chapter 7 of this
boolclet: Aski��g irs to pay oi�r shar�e of a bill yoa� have received for• cove�°ed medical
se�vices or d�°ugs. Chapter 7 describes the situations in which you inay need to aslc for
reimbursement. It also tells how to send us the paperwork that asks us to pay you back for
our share of the cost of a drug you have paid for.
If you are requesting an exceptiou, provide the "supportiug statement." Your doctor
or other prescriber must give us the medical t•easons for the drug exception you are
requesting. (We call this the "supporting statement.") Your doctoi• or other prescriber can
fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone
and follow up by faxing or mailing a written statement if necessary. See Sections 6.2 and
6.3 for more inforn�ation about exception requests.
If you�° health requir�es it, ask us to give yozr a` fast cover•age decision"
Legal A"fast coverage decision" is called an "expedited coverage determination."
Terms
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Cl�apter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
If we do not meet this deadline, we are required to send your request on to Level 2
of the appeals process, whej•e it will be reviewed by an independent outside
organization. Later in this section, we tell about this review organization and
explain what happens at Appeal Level 2.
If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 24 hours after we receive your i�equest or
doctor's statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a wt•itten
statement that explains why we said no.
Deadlines foN a"standar�l" cove��age decision aboz�t a dri�g you hcrve not yet �•eceived
• If we are using the standard deadlines, we must give you our answer within 72 hours.
• Generally, this means within 72 hours after we receive your request. If you are
requesting an exception, we will give you our answer within 72 houis after we
receive your doctor's statement supporting your request. We will give you ow�
answer sooner if your health requires us to.
• If we do not meet this deadline, we are required to send your request on to Level 2
of the appeals process, where it will be reviewed by an independent organization.
Later in this section, we tell about this review organization and explain what
happens at Appeal Level 2.
If our answer is yes to part or all of what you requested —
• If we approve your request for coverage, we must provide the coverage we have
agreed to provide within 72 hours after we receive your request or doctor's
statement supporting your request.
• If our answer is no to part or all of what you requested, v��e will send you a written
statement that e�plains why we said no.
Deadlines for a"slandard" cover�age deciszon about perymeni for cr dri�g yoz� have already
bortgl�t
• We must give you our answer within 14 calenclar days after we receive your request.
• If we do not meet this deadline, we are required to send your request on to Leve12
of the appeals process, where it will be reviewed by an independent organization.
Later in this section, we tell about this review organization and e�plain what
happens at Appeal Level 2.
• If our answer is yes to part or all of what you requested, we are also required to malce
payment to you within 14 calendar days after we receive your request.
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If you wish, you and your doctor or other prescriber may give us additional
information to support your appeal.
If yo�atr� health req�uires it, ask fof° a` fast ap�eal "
Legal A"fast appeal" is also called an "expedited redetermination."
Terms
If you are appealing a decision we made about a drug you have not yet received, you and
your doctor or other prescriber will need to decide if you need a"fast appeal."
The requu•ements for getting a"fast appeal" are the same as those for getting a"fast
coverage decision" in Section 6.4 of this chapter.
Step 2: Our plan considers your appeal and we give you our answer.
• When we are reviewing your appeal, we talce another careful look at all of the
information about your coverage request. We check to see if we were following all the
rules when we said no to your request. We may contact you or your doctor or other
prescriUer to get more information.
Deadlines fo�� cr `fast" appeal
• If we are using the fast deadlines, we must give you our answer within 72 hours after
we receive your appeal. We will give you our answer sooner if your health requires it.
• If we do not give you an answer within 72 hours, we are required to send your
request on to Level 2 of the appeals process, where it will be reviewed by an
Independent Review Organization. Later in this section, we tell about this review
organization and explain what happens at Leve12 of the appeals process.
If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 72 hours after we receive your appeal.
If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.
Deadlines fof� a "standttrd" appeal
• If we are using the standard deadlines, we tnust give you our answer within 7 caleudar
days after we receive your appeal. We will give you our decision sooner if you have not
received the drug yet and your health condition i•equit•es us to do so. If you believe youl•
health requit�es it, you should aslc for a"fast" appeal.
• If we do not give you a decision within 7 calendar days, we are required to send
your request on to Level 2 of the appeals process, where it will be reviewed by an
Independent Review Ol•ganization. Latei• in this section, we tell about tllis i•eview
organization and explain what happens at Level 2 of the appeals process.
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Step 2: The Independent Review Organization does a review of your appeal and gives you
an answer.
• The Independent Review Organization is an independent organization that is hired
by Medicare. This organization is not connected with us and it is not a government
agency. This organization is a company chosen by Medicare to review our decisions
about your Part D beneftts with us.
Reviewers at the Independent Review Organization will take a careful loolc at all of the
information related to your appeal. The organization will tell you its decision in writing
and explain the reasons for it.
Deadlines for `f«st" appeal at Level 2
• If your health requires it, ask the Independent Review Organization for a"fast appeal."
If the review organization agrees to give you a"fast appeal," the review organization
must give you an answer to your Level 2 Appeal within 72 hours after it receives your
appeal request.
If the Independent Review Organization says yes to part or all of what you
requested, we must provide the drug coverage that was approved by the review
organization within 24 hours after we receive the decision fi•om the r•eview organization.
Deacllines fo�� "stutida��d" appeul at Level 2
• If you have a standard appeal at Level 2, the review organization must give you an
answer to your Leve12 Appeal within 7 calendar days after it receives your appeal.
If the Independent Review Organization says yes to part or all of what you
requested —
• If the Independent Review Organization approves a request for coverage, we must
I�rovide the drug coverage that was approved by the review organization withiu
72 hours after we receive the decision fi•om the review organization.
If the Independent Review Organization appi•oves a request to pay you bacic for a
drug you already bought, we are required to send payment to you within 30
calendar days after we receive the decision fi•om tl�e review organization.
What if the review organization says no to your appeal?
If this organization says no to your appeal, it means the organization agrees with our decision not
to approve your request. (This is called "upholding the decision." It is also called "tllrning down
your appeal.")
To continue and make another appeal at Level 3, the dollar value of the drug coverage you are
i•equesting must meet a mininlum amount. If the dollar value of the coverage you are requesting
is too low, you cannot make another appeal and the decision at Level 2 is finaL The notice you
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printed on the back cover of this booklet). You can also call 1-800-MEDICARE (1-800-633-
4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
1. Read this notice cai•efully and ask questions if you don't understand it. It tells you
about your rights as a hospital patient, including:
• Your right to receive Medicare-covered services during and after your hospital
stay, as ordered by your doctor. This includes the right to know what these
services are, who will pay for them, and where you can get them.
Your right to be involved in any decisions about your hospital stay, and know
who will pay for it.
Where to report any concerns you have about quality of your hospital care.
Your right to appeal your discharge decision if you think you are being
dischat•ged from the hospital too soon.
Legal The written notice fi•om Medicare tells you how you can "request an immediate
Terms review." Requesting an immediate review is a formal, legal way to ask for a delay in
your discharge date so that we will cover your hospital care for a longer time.
(Section 7.2 below tells you how you can request an immediate review.)
2. You must sign the written notice to show that you received it and understand your
rights.
• You or someone who is acting on your behalf must sign the notice. (Section 4 of
this chapter tells how you can give written permission to someone else to act as
your representative.)
Signing the notice shows only that you have received the information about your
rights. The notice does not give your discharge date (your doctor or hospital staff
will tell you your discharge date). Signing the notice does not mean you are
agreeing on a discharge date.
Keep your copy of the signed notice so you will have the information about inaking an
appeal (or i•eporting a concern about quality of care) handy if you need it.
• If you sign the notice mol•e than 2 days before the day you leave the hospital, you
will get another copy before you are scheduled to be discharged.
To look at a copy of this notice in advance, you can call Member Set�vices (phone
numbers are printed on the back cover of this booklet) or 1-800 MEDICARE (1-
800-633-4227), 24 hours a day, 7 days a weelc. TTY users should call 1-877-486-
2048. You can also see it online at http://www.cros.gov/BNI/12 Hospital
DischargeAppealNotices.asp.
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If you meet this deadline, you are allowed to stay in the hospital after• your
discharge date lvithout pcc��ing for it while you wait to get the decision on youi•
appeal fi•om the Quality Improvement Ot•ganization.
If you do not meet this deadline, and you decide to stay in the hospital after your
planned discharge date, yoz� �nay have to pay all of the costs for hospital care you
receive after you►• planned discharge date.
If you miss the deadline for contacting the Quality Impt•ovement Organization about your
appeal, you can make your appeal directly to our plan instead. For details about this other
way to make your appeal, see Section 7.4.
Ask for a` fast review ":
• You must ask the Quality Improvement Organization for a"fast review" of your
discharge. Asking for a"fast review" means you are asking for the organization to use the
"fast" deadlines for an appeal instead of using the standard deadlines.
Legal A"fast review" is also called an "immediate review" or an "expedited review."
Terms
Step 2: The Quality Improvement Organization conducts an independent review of your
case.
What happens da�ring this Yevielv?
• Health professionals at the Qliality Improvement Organization (we will call them "the
reviewers" for short) will ask you (or your t�epresentative) why you believe coverage for
the services should continue. You don't have to prepare anything in writing, but you may
do so if you wish.
The reviewers will also look at your medical information, talk with your doctor, and
review information that the hospital and we have given to them.
By noon of the day aftel• the reviewers informed our plan of yow� appeal, you will also get
a written notice that gives your planned discharge date and explains in detail the reasons
why your doctor, the hospital, and we think it is right (medically appropriate) for you to
be discharged on that date.
Legal Tl�is written explanation is called tl�e "Detailed Notice of Discharge." You can get
Terms a sample of this notice by calling Member Services (phone numbers are printed on
the back cover of this booklet) or 1-800-MEDICARE (1-800-633-4227, 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.) Or you can see a
sa�nple notice online at http://www.cros,hhs.govBNI/
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Step 2: The Quality Improvement Organization does a second review of your situation.
• Reviewers at the Quality Improvement Organization will take another careful loolc at all
of the information related to your appeal.
Step 3: Within 14 calendar days, the Quality Improvement Organization reviewers will
decide on your appeal and tell you their decision.
If the revieiv o��gcrnization says yes:
• We must reimburse you for our share of the costs of hospital care you have received
since noon on the day after the date your first appeal was turned down by the Quality
Improvement Oi•ganization. We must continue providing coverage for your inpatient
hospital care for as long as it is medically necessary.
You must continue to pay your share of the costs and covet�age limitations may apply.
If the revie�v ofganization scrys no:
• It means they agree with the decision they made on your Level 1 Appeal and will not
change it.
The notice you get will tell you in writing what you can do if you wish to continue with
the review process. It will give you the details about how to go on to the next level of
appeal, which is handled by a judge.
Sten 4: If the answer is no, you will need to decide whether you want to take your appeal
further by going on to Leve13.
• There are three additional levels in the appeals process after Level 2(for a total of five
levels of appeal). If the review organization turns down your Level 2 Appeal, you can
choose whether to accept that decision or whether to go on to Level 3 and make another
appeal. At Level 3, your appeal is reviewed by a judge.
Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
Section 7.4 What if you miss the deadline for making your Level 1 Appeal?
You can appeal to us instead
As explained above in Section 7.2, you must act quickly to contact the Quality Improvement
Organization to start your fitst appeal of your hospital discharge. ("Quicicly" means before you
leave the hospital and no later than your planned discharge date). If you miss the deadline for
contacting this organization, tl�ere is another way to make your appeal.
If you use this othel• way of tnalcing youl• appeal, the first ttvo levels of ap�eal are different.
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To make sure we were following all the rules when we said no to your fast appeal, we
are required to send your appeal to the "Independent Review Organization." When
we do this, it means that you are azctomatically going on to Level 2 of the appeals
process.
Step-by-Step: How to make a Leve12 Altern�ite Appeal
If we say no to your Level 1 Appeal, your case will autonacrtically be sent on to the next level of
the appeals process. During the Leve12 Appeal, the Independent Review Organization reviews
the decision we made when we said no to your "fast appeal." This organization decides whether
the decision we made should be changed.
Legal The formal name for the "Independent Review Organization" is the "Independent
Terms Review Entity." It is sometimes called the "IRE."
Step l; We will automatically forward your case to the Independent Review Organization.
• We are requu•ed to send the information for your Level 2 Appeal to the Independent
Review Organization within 24 hours of when we tell you that we are saying no to your
first appeal. (If you think we ai�e not meeting this deadline or other deadlines, you can
malce a complaint. The complaint process is different fi�om the appeal process. Section 10
of this chapter tells how to make a complaint.)
Sten 2: The Independent Review Organization does a"fast review" of your appeal. The
reviewers give you an answer within 72 hours.
• The Independent Review Organization is an independent organization that is l�ired
by Medicare. This organization is not connected with our plan and it is not a government
agency. This organization is a cotnpany chosen by Medicare to handle the job of being
the Independent Review Organization. Medicare ovei•sees its work.
Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal of yout� hospital discharge.
If this organization says yes to your appeal, then we must reitnburse you (pay you
back) for our share of the costs of hospital care you have received since the date of your
planned dischat�ge. We must also continue the plan's coverage of your inpatient hospital
services for as long as it is medically necessaty. You must continue to pay your share of
the costs. If there are covei•age limitations, these could limit how much we would
reiinburse or how long we would continue to cover your seivices.
If this organization says no to your appeal, it means they agree with us that your
planned hospital discharge date was medically appropriate.
• The notice you get fi•om the Independent Review Organizatiou will tell you in
writing what you can do if you wish to continue with the i•eview pi•ocess. It will
give you the details about how to go on to a Level 3 Appeal, which is handled by
a judge.
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Section 8.2 We will tell you in advance when your coverage will be ending
You receive a notice in writing. At least two days before our plan is going to stop
covei•ing your care, the agency or facility that is providing your care will give you a letter
or notice.
- The wcitten notice tells you the date when we will stop covei•ing the care foi• you.
The written notice also tells what you can do if you want to ask our plan to
change this decision about when to end your care, and keep covering it for a
longer period of time.
Legal In telling you what you can do, the written notice is telling how you can request a
Terms "fast-track appeal." Requesting a fast-track appeal is a formal, legal way to request
a change to our coverage decision about when to stop your care. (Section 8.3 below
tells how vou can request a fast-tracic appeal.) _
Legal The written notice is called the "Notice of Medicare Non-Coverage." To get a
Terms sample copy, call Member Services (phone numbers at�e printed on the back cover of
this booklet) or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. (TTY users should call 1-877-486-2048.) Or see a copy online at
htta://www.cros.hhs. govBNI/
2. You must sign the written notice to show that you received it.
• You or someone who is acting on your behalf must sign the notice. (Section 4
tells how you can give written permission to someone else to act as your
representative.)
Signing the notice shows only that you have received the information about when
your coverage will stop. Signing it does not mean you agree with the plan that
it's time to stop getting the care.
Section 8.3 Step-by-step: How to malce a Level 1 Appeal to have our plan cover
your care for a longer time
If you want to aslc us to cover your care for a longer period of time, you will need to use tlie
appeals process to tnake this request. Before you start, understand what you need to do and what
the deadlines are.
• Follow the process. Each step in the first two levels of the appeals process is explained
below.
� Meet the deacllines. The deadlines ai•e impoi•tant. Be sui•e that you understand and follow
the deadlines that apply to things you must do. There are also deadlines oui• plan must
follow. (If you thinlc we are not nleeting our deadlines, you can file a complaint. Section
10 of this chapter tells you how to file a conlplaint.)
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The review organization will also look at your medical infol•mation, talk with your
doctor, and review information that our plan has given to them.
By the end of the day the reviewers informed us of your appeal, and you will also get a
written notice fi•om us that explains in detail our reasons for ending our coverage for your
services.
Legal This notice explanatron is called the "Detailed Explanation of Non-Coverage."
Terms
Step 3: Within one full day after they have all the information they need, the reviewers will
tell you their decision.
Whcrt happens if the reviewer�s scry yes to your appeal?
• If the revieweis say yes to your appeal, then we must lceep provicliug your covered
services for as long as it is medically necessary.
You will have to keep paying your share of the costs (such as deductibles or copayments,
if these apply). In addition, there may be limitations on your covered services (see
Chapter 4 of this booklet).
What happens if the revietiver•s scry no to you�� a�peal?
• If the reviewers say no to your appeal, then your coverage will end on the date we have
told you. We will stop paying our share of the costs of this care.
If you decide to keep getting the home health care, or skilled nursing facility care, or
Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when
your coverage ends, then you will have to pay the full cost of this care yourself.
Step 4: If tl�e answer to your Level 1 Appeal is no, you decide if you want to make another
appeal.
• This first appeal you make is "Level 1" of the appeals process. If reviewers say no to
your Level 1 Appeal — and you choose to continue getting care after your coverage for
the care has ended — then you can make another appeal.
Making another appeal means you are going on to "Level 2" of the appeals process.
Section 8.4 Step-by-step: How to make a Level 2 Appeal to have our plan cover
your care for a longer time
If the Quality Improvement Organization has tui•ned down youi• appeal and you choose to
continue getting care after your coverage for the care has ended, then you can make a Level 2
Appeal. Dui•ing a Level 2 Appeal, you ask the Quality Improvement Organization to talce anothei•
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Section 8.5 What if you miss the deadline for inaking your Level 1 Appeal?
You can appeal to us instead
As explained above in Section 8.3, you must act quickly to contact the Quality Impl•ovement
Organization to start your first appeal (within a day or two, at the most). If you miss the deadline
for contacting this organization, there is another way to make your appeal. If you use this other
way of making your appeal, the first t�vo levels of appeal are different.
Step-by-Step: How to malce a Level l Alternate Appeal
If you miss the deadline for contacting the Quality Improvement Organization, you can make an
appeal to us, asking for a"fast review." A fast review is an appeal that uses the fast deadlines
instead of the standard deadlines.
Here al•e the steps for a Level 1 Altet�nate Appeal:
Legal A"fast" review (or "fast appeal") is also called an "expedited appeal".
Terms
Step 1; Contact our plan and ask for a"fast review."
• For details on how to contact us, go to Chapter 2, Section 1 and look for the section
called, How to contact our• plc�rr i�vhen yozr a�e making an� appeal about yozn• medical
care.
Be sure to ask for a"fast review." This means you are asking us to give you an answer
using the "fast" deadlines rather than the "standard" deadlines.
Step 2; We do a"fast" review of the decision we made about when to end coverage for your
services.
• During this review, we take another look at all of the information about your case. We
check to see if we were following all the rules when we set the date for ending the plan's
coverage for services you were receiving.
• We will use the "fast" deadlines rathel• than the standat�d deadlines for giving you the
answer to this review. (Usually, if you make an appeal to our plan and ask for a"fast
review," we are allowed to decide whether to agree to your request and give you a"fast
review." But in this situation, the rules require us to give you a fast response if you ask
for it.)
Step 3: We give you our decision within 72 hours after you aslc for a"fast review" ("fast
appeal").
• If �ve say yes to youi• fast appeal, it means we llave agreed with you that you need
se�vices longer, and will keep providing your covered selvices for as long as it is
medically necessary. It also means that we have agreed to reimburse you for our shai•e of
the costs of car•e you have received since the date when we said your coverage would
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If this organization says yes to your appeal, then we must reimburse you (pay you
bacic) for ow� share of the costs of care you have received since the date when we said
your coverage would end. We must also continue to cover the care for as long as it is
medically necessaiy. You must continue to pay your share of the costs. If there are
coverage limitations, these could limit how much we would reimburse ot• how long we
would continue to cover your services.
If this organization says �2o to your appeal, it means they agree with the decision our
plan made to your fit�st appeal and will not change it.
• The notice you get fi•om the Independent Review Organization will tell you in
writing what you can do if you wish to continue with the review process. It will
give you the details about how to go on to a Leve13 Appeal.
Step 3: If the Independent Review Organization turns down youi• appeal, you choose
whether you want to talce your appeal further.
• There are three additional levels of appeal after Level 2, for a total of five levels of
appeal. If reviewers say no to your Level 2 Appeal, you can choose whether to accept that
decision or whether to go on to Level 3 and make another appeal. At Level 3, your appeal
is reviewed by a judge.
Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.
SECTION 9
Section 9.1
Taking your appeal to Level 3 and beyond
Levels of Appeal3, 4, and 5 for Medical Service Appeals
This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2
Appeal, and both of your appeals have been turned down.
If the dollar value of the item or medical service you have appealed nleets certain minimulll
levels, you may be able to go on to additional levels of appeaL If the dollar value is less than the
miniinum level, you cannot appeal any fiu•ther. If the dollar value is high enough, the written
response you receive to your Level 2 Appeal will explain who to contact and what to do to aslc
for a Level 3 Appeal.
For most situations that involve appeals, the last three levels of appeal worlc in much the same
way. Here is who handles the review of your appeal at each of these levels.
Level 3 Appeal
A judge who works for the federal govei•nment will i•eview your appeal
and give you an answer. This judge is called an "Administrative Law
r_,__»
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Leve15 Appeal A judge at the Federal District Court will review your appeal.
This is the last step of the administt�ative appeals process.
Section 9.2 Levels of Appeal3, 4, and 5 for Part D Drug Appeals
This section may be appi•opi•iate for you if you have made a Level 1 Appeal and a Level 2
Appeal, and both of your appeals have been turned down.
If the dollar value of the drug you have appealed meets certain minimum levels, you tnay be able
to go on to additional levels of appeal. If the dollar value is less than the minimum level, you
cannot appeal any further. If the dollar value is high enough, the written response you receive to
your Level 2 Appeal will explain who to contact and what to do to ask fot� a Level 3 Appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
Leve13 Appeal A judge who works for the federal government will review your appeal
and give you an answer. This judge is called an "Administrative Law
If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was approved by
the Adtninistrative Law Judge within 72 hours (24 hours for expedited appeals) or
make payment no later than 30 calendar days after we receive the decision.
If the answer is no, the appeals process fnay or mtry not be over.
• If you decide to accept this decision that tui•ns down your appeal, the appeals
process is over.
If you do not want to accept the decision, you can continue to the next level of the
review pS�ocess. If the adtninisti•ative law judge says no to your appeal, the notice
you get will tell you what to do next if you choose to continue with your appeal.
Leve14 Appeal The Meclicare Appeals Council will review your appeal and give you an
answer. The Medica�•e Appeals Council works fol• the federal government.
� If the answer is yes, the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was approved by
the Medicare Appeals Council within 72 hours (24 hours for expedited appeals) or
make payment uo later than 30 calendar days after we receive the decision.
• If the answer is no, the appeals process n�trry or m�ry not be over.
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Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals,
complaints)
If you have any of tl�ese kinds of problems,
you can "make a complaint"
Quality of your medical care
• Are you unhappy with the quality of the care you have received (including care in the
hospital)?
Respecting your privacy
• Do you believe that someone did not respect your right to prrvacy or shared infot•mation
about you that you feel should be confidential?
Disrespect, poor custoiner service, or other negative behaviors
• Has someone been rude or disrespectful to you?
• Are you unhappy with how out� Member Services has treated you?
• Do you feel you are being encout�aged to leave the plan?
Waiting times
• Are you having trouble getting an appointment, or waiting too long to get it?
• Have you been kept waiting too long by doctors, pharmacists, or other health
pt•ofessionals? Or by our Member Services or other staff at the plan?
• Examples include waiting too long on the phone, in the waiting room, when
getting a prescription, or in the exam room.
Cleanliness
• At•e you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's
office?
Information you get from us
j• Do you believe we have not given you a notice that we are required to give?
�• Do you think written information we have given you is hard to understand?
The next page has moNe examples of possible r•ecrsons fof�� rraaking a co�nplaint
Possible complaints
These types of complaints are all related to the timeliness of our actions related to
coverage decisions ancl appeals
The process of asking foi• a coverage decision and making appeals is explained in sections 4-9
of this chaptei•. If you are asking for a decision or making an appeal, you use that process, not
the complaint process.
However, if you have already asked us for a coverage decision or made an appeal, and you
think that we are not responding quickly enough, you can also malce a complaint about our
slowness. Here are examples:
,• If you have asked us to give you a"fast coverage decision" or a"fast appeal," and we
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Chapter 9: What to do if you have a problem or complaint (cover•age decisions, appeals,
complaints)
Be sure to provide all pertinent infot•mation or you may also download the form
on our website at: http://www.aetnamedicare.com/help_and_resources/
downloadable fot•ms 2012.jsp?tab=4 and select the "Aetna Medicare Grievance
Form" located in the Exception, Appeals and Grievances Fortns section of the
site.
The grievance must be submitted within 60 days of the event or incident. Your
issue will be investigated by a grievance analyst who did not have any previous
involvement with your issue. For written complaints, you will receive a written
notice stating the result of our review, which will be sent to you. This notice will
include a description of our ttnderstanding of your grievance, and our decision in
clear terms. We must address your grievance as quickly as your case requires
based on your health status, but no later than 30 days after receiving your
complaint. We may extend the time fi�ame by up to 14 days if you ask fot� an
extension oi• if we identify a need fot� additional information and the delay is in
your best interest.
• You also have the right to ask for a fast "exped'rted" grievance. An expedited or
"fast" grievance is a type of complaint that must be resolved within 24 hours from
the time you contact us. You have the right to request a"fast" grievance if you
disagree with:
• Our plan to take a 14-day extension on an organization determination or
reconsideration, or
• Our denial of your request to expedite an organization detet•mination or
reconsideration for health services or
Our denial of your request to expedite a coverage determination or
redetermination for a prescription drug.
• The expedited/fast grievance process is as follows: You ol• an authorized
representative may call, fax, or mail your complaint and mention that you want
the fast, or expedited, grievance process. Call 1-888-267-2637, fax your
complaint to 1-866-604-7092, or write your complaint and send it to the address
shown in tl�e paragraph above. Upon receipt of the complaint, we will promptly
investigate the issue you have identified. If we agree with your coinplaint, we will
cancel the 14-day eYtension, or eYpedite the determination or appeal as you
originally requested. Regardless of whethei• we agi•ee or not, we will notify you of
our decision by phone within 24 houi•s and se»d wi•itten follow-up shortly
tl�ei•eafter.
• Whether you call or write, you should contact Member Services right away. The
complaint must be made within 60 calendar days after you had the problem you want to
complain about.
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Chapter 9: What to do if you have a pi•oblem or complaint (coverage decisions, appeals,
complaints)
Section 10.5 You can also tell Medicare about your complaint
You can submit a complaint about our plan directly to Medicare. To submit a complaint to
Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your
complaints seriously and will use this infarmation to help improve tl�e quality of the Medicare
program.
If you have any other feedbacic or concerns, or if you feel the plan is not addressing your issue,
please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.
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Chapter 10: Ending your membership in the plan
SECTION 1 Introduction
Section Ll This chapter focuses on ending your membership in our plan
Ending your membership in our plan may be voluntary (your own choice) or involuntary (not
your own choice):
• You might leave our plan because you have decided that you �-nant to leave.
• As a member of an employer/uuion/ti•ust group retiree plan, you may voluntarily
end your membership at any time. There are also certain specific times during the
year, or certain situations, when you may voluntarily end your membership in the
plan. Section 2 tells you when you can end your membership in the plan. .
The process for voluntarily ending your membership varies depending on what
type of new coverage you are choosing. Section 3 tells you ho�v to end your
membership in each situation.
There are also limited sittitations where you do not choose to leave, but we are required to
end your membeiship. Section 5 tells you about situations when we must end your
membership.
If you are leaving om� plan, you must continue to get your medical care and prescription drugs
through our plan until your membership ends.
It is important that you consult with your plan benefits administrator be of•e dropping your
group retiree coverage. This is important because you may permanently lose beneiits you
currently receive under your employer or retiree group coverage if you switch plans.
SECTION 2 When can you end your membership in our plan?
Because you are enrolled in our plan through your former employer/union/trust, some of the
information in this chapter does not apply to you, because you are allowed to make plan changes
at other times permitted by your plan sponsor. However, if you ever choose to discontinue your
group i•etiree health plan coverage, the infortnation in this chapter will apply to you.
If your foril�er employer/union/trust plan holds an annual Open Enrollment Period, you tnay be
able to make a change to your health coverage at that time. Your plan benefits administrator will
let you know when your Open Enrollment Period begins and ends, what plan choices are
available to you, and the effective date of coverage.
All membeis have the opportunity to leave the plan during the Annual Enrollment Period and
during the annual Medicare Advantage Diseni•ollment Pei•iod. In certain sihtations, you may also
be eligible to leave the plan at other times of the yeac. Because of your special situation
(enrollment through youi• former einployer/union/trlist's group plan) you are eligible to end your
membei•ship at any time through a Special Enl•olltnent Period (see Section 2.3).
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Chapter 10: Ending your membership in the plan
Wl�at type of plan can you switch to during the annual Medicare Advantage
Disenrollment Period? During this time, you can cancel your Medicare Advantage Plan
enrollment and switch to Original Medicare. If you choose to switch to Original Medicare
during this period, you have until Febi•uary 14 to join a separate Medicare prescription
drug plan to add drug coverage.
When will your membership end? Your membership will end on the first day of the
month after we get your request to switch to Original Medicare. If you also choose to
enroll in a Medicare prescription drug plan, your membership in the drug plan will begin
the first day of the month after the drug plan gets your enrollment request.
Section 2.3 In certain situations, you can end your membership during a Special
Enrollment Period
In certain situations, membeis of our plan may be eligible to end their membership at other times
of the yeaz�. This is known as a Special Enrollment Period.
• Who is eligible for a Special Enrollment Period? If any of the following situations
apply to you, you are eligible to end your me�nbeiship dui•ing a Special Enrollment
Period. These are just examples, for the full list you can contact the plan, call Medicare,
or visit the Medicare website (http://www.medicare.gov):
• Usually, when you have moved.
• If you have Medicaid.
• If you are eligible for E�ra Help with paying for your Medicare prescriptions.
• If we violate our contract with you.
• If you are getting care in an institution, such as a nursing home ot� long-term care
hospital.
• If you enroll in the Program of All-inclusive Care for the Elderly (PACE).
• If you are enrolled in an employer/union/trust group plan.
It is important that you consider your decision to disenroll from our plan carefully PRIOR
to disenrolling. Since disenrollment from our plan could affect your employer or union
health beneiits, you could permanently lose your employer or union health coverage. If you
are considering disenrolling from our plan and have not done so already, please consult
with your plan beneiits administrator.
• When are Special Enrollment Periods? The enrollment periods vary depending on your
situation.
• What can you do? To find out if you are eligible for a Special Enrollment Period, please
call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY usets call 1-877-486-2048. If you at�e eligible to end your membership because of a
special situation, you can choose to change both your Medicare health coverage and
prescription drug coverage. This means you can choose any of the following types of
plans:
• Another Medicare health platl. (You can choose a plan that covers prescription
drugs or one that does not cover prescription drugs.)
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Chapter 10: Ending your membel•ship in the plan
prescription drug plan, you must aslc to be disenrolled from our plan. There are two ways you
can ask to be disenrolled:
• You can make a request in writing to us. Contact Member Services if you need more
infortnation on how to do this (phone numbe��s are printed on the bacic of your member
ID card.
--o��--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048.
Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage, you may need to pay a late enrollment penalty if
you join a Medicare drug plan later. ("Creditable" coverage means the coverage is
expected to pay, on average, at least as much as Medicare's standard prescription drug
coverage.) See Chapter 6, Section 10 for more information about the late enrollment
penalty.
The table below explains how you should end your tnembership in our plan.
If you would like to switch from our
plan to:
• An individual Medicare health
plan.
This is what you should do:
• Enroll in the new Medicare health
plan.
You will automatically be disenrolled
fi�om our plan when your new plan's
coverage begins.
Original Medicare ��ith a
separate Medicare prescription
drug plan.
Original Medicare ivithout a
separate Medicare prescription
drug plan.
Note: If you disenroll fi�om a
Medica►•e prescription drug plan
and go without creditable
prescription drug coverage, you
may need to pay a late
enrollment penalty if you join a
Medicare drug plan later. See
Chapter 6, Section 10 for more
infortnation about the late
• Enroll in the new Medicare
prescription drug plan.
You will automatically be disenrolled
fi•om our plan when your new plan's
coverage begins.
• Send us a written request to
disenroll. Contact Member Services if
you need mol•e infol•mation on how to
do this (phone numbers are printed on
the back of youl• member ID card).
• You can also contact Medicare, at 1-
800-MEDICARE (1-800-633-4227),
24 hout•s a day, 7 days a week, and
ask to be disenrolled. TTY users
should call l -877-486-2048.
• You will be disenrolled fronl our plan
when your coverage in Original
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Chapter 10: Ending your membership in the plan
• If you intentionally give us incorrect infoi•mation when you are enrolling in our plan and
that information affects your eligibility fot� our plan. (We cannot make you leave our plan
for this reason unless we get permission fi•om Medicare first.)
If you continuously behave in a way that is disruptive and malces it difficult for us to
provide medical care for you and other members of our plan. (We cannot make you leave
our plan for this reason ltnless we get permission fi•om Medicare first.)
If you let someone else use your membership card to get medical care or prescription
drugs. (We cannot make you leave our plan for this reason unless we get permission fi•om
Medicare first.)
• If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.
If you do not pay the plan premiums (if applicable) for three months.
• We must notify you in writing that you ha�e three months to pay the plan
premium before we end your membership.
If you have Medicaid and are having difficulty paying your plan premiums or cost
sharing, please contact us.
If you are required to pay the extra Part D amount because of your income and you do not
pay it, Medicare will disenroll you fi•om our plan and you will lose prescription drug
coverage.
Where can you get more information?
If you have questions or would like more information on when we can end your membership:
• You can call Member Services for more information (phone numbers are printed on tl�e
back cover of this booklet).
Section 5.2 We cannot ask you to leave our plan for any reason related to your
health
What should you do if this happens?
If you feel that you are being asked to leave our plan because of a l�ealth-related reason, you
should call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-
486-2048. You may call 24 hours a day, 7 days a week.
Section 5.3 You have the right to malce a cotnplaint if we end your membership in
our plan
If we end your metnbership in oui• plan, we mtiist tell you our reasons in writing for ending your
meinbeiship. We must also eYplain how you can make a con�plaint about our decisioi� to end
your inembey�ship. You can also look in Chaptei• 9, Section 10 foi• infot�ination about how to make
a complaint.
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Chapter 11: Legal notices
SECTION 1 Notice about governing law
Many laws apply to this Evidence of Coverage and some additional provisions may apply
because they are required by law. This may affect your rights and responsibilities even if the
laws are not included or explained in this document. The principal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under the Social
Security Act by the Centers for Medicar•e & Medicaid Services, or CMS. In addition, other
federal laws may apply and, under certain circumstances, the laws of the state you live in.
SECTION 2 Notice about nondiscrimination
We don't discriminate based on a person's race, disability, religion, sex, health, ethnicity, creed,
age, or national origin. All organizations that pi•ovide Medicare Advantage Plans, like our plan,
must obey federal laws against discr�imination, including Title VI of the Civil Rights Act of
1964, the Rehabilitation Act of 1973, tl�e Age Discrimination Act of 1975, the Americans with
Disabilities Act, all other laws that apply to organizations that get federal funding, and any other
laws and rules that apply for any other reason.
SECTION 3 Notice about Medicare Secondary Payer subrogation rights
and right of recovery
We have the right and responsibility to collect for covered Medicare services for which Medicare
is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and
423.462, Aetna Medicare, as a Medicare Advantage Organization, will exercise the satne rights
of recoveiy that the Secretary exercises under CMS regulations in subparts B through D of part
411 of 42 CFR and the rules established in this section supersede any State laws.
In sonze situations, other parties should pay for your tnedical care before your Medicare
Advantage (MA) health plan. In those situations, your Medicare Advantage plan may pay, but
has the right to get the payments bacic fi•om these other parties. Medicare Advantage plans may
not be the primary payer for medical care you receive. These situations include those in which
the Federal Medicare Program is considered a secondary payer under the Medicare Secondary
Payer laws. For information on the Federal Medicare Secondary Payer program, Medicare has
written a booklet with general infot•mation about what happens when people with Medicare have
additional insurance. It's called lYledicar�e a��d Othe�� Health Benefrts: Your Guide to Who Pays
Fii�st (pzrblzcation nzrmbei° 02179). You can get a copy by calling 1-800-MEDICARE, 24 hours a
day, 7 days a week, or by visiting the www.medicare.gov web site.
The plan's rights to recover in these situations are based on the terms of this health plan contract,
as well as the provisions of the federal statutes governing the Medicare Program. Your MA plan
coverage is always secondary to any payment made or reasonably expected to be made undei•:
• A worlcei•s' compensation law or plan of the United States or a State,
• Any non-fault based insurance, including automobile and non-automobile no-fault and
medical payments insurance,
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Chapter l l: Legal notices
benefits the plan provided or purports to allocate any portion of such settlement oi• judgment to
payment of expenses other than medical expenses. The MA plan is entitled to recover from any
and all settlements or judgments, even those designated as for pain and suffering, non-economic
damages and/or genet�al damages only.
You, and your legal representatives, shall fully coopei•ate with the plan's efforts to recovel• its
benefits paid. It is your duty to notify the plan within 30 days of the date when notice is given to
any party, including an insurance company or• attorney, of your intention to pursue or investigate
a claitn to recover damages or obtain compensation due to your injury, illness or condition. You
and your agents or representatives shall provide all information requested by the plan oi• its
representatives. You shall do nothing to prejudice your MA plan's subrogation or recovery
interest or to prejudice the plan's ability to enforce the terms of this provision. This includes, but
is not limited to, refi•aining from making any settlement or recovery that attempts to reduce or
exclude the full cost of all benefits provided by the plan.
Failure to provide requested information or failure to assist your MA plan in pursuit of its
subrogation or recoveiy rights may result in you being personally responsible for reimbursing the
plan for benefits paid relating to the injury, illness or condition as well as for the plan's
t•easonable attorney fees and costs incurred in obtaining reimbursement from you. For more
information, see 42 U.S.C. § 1395y(b)(2)(A)(ii) and the Medicare statutes.
SECTION 4 Notice about binding arbitration
Binding arbitration is the final and exclusive process for t�esolving any dispute between a
member and the Plan, other than those brought under the Medicare Appeals Procedure. All
interested parties are giving up theu� constitutional right to ha�e theit• dispute decided in a court
of law before a jury, and instead are accepting the use of binding arbitration.
The agreement to arbitrate includes bad faith claims and disputes that relate to professional
liability or medical malpractice.
This Evidence of Coverage also limits certain remedies such as:
• No jut•y trial: In any dispute arising fi�om or related to coverage, there shall be no t•ight to
a jury trial. This right to trial is waived.
• Medical malpractice claims: Any claim alleging wrongful acts or omissions of
participating providers will not include the Aetna Medicare plan and will only include the
participating provider subject to this allegation. Members waive their right to bring any
claim against Aetna as a party to this claitn.
Class actions: Members cannot participate in a representative capacity as a member of
any class actions relating to plan coverage. Claims brought by members may not be
joined or consolid�ted with claiu7s brought by another member, unless agreed to in
writing by Aetna.
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Chapter 12: Definitions of impoi•tant words
Chapter 12 Definitions of important words
Ambulatory Surgical Center — An ambulatoiy surgical center is an entity that operates
exclusively for the purpose of furnishing outpatient surgical services to patients not requiring
hosp"rtalization and whose expected stay in the centet• does not eYceed 24 hours.
Annual Enrollment Period — A set time each fall when all Medicat•e members can change their
health or drug plans o1• switch to Original Medicare. The general Medicare Annual Enrollment
Period is from October 15 until December 7.
Appeal — An appeal is sotnething you do if you disagree with our decision to deny a request for
coverage of health care services or payment for seivices you already received. You may also
make an appeal if you disagree with our decision to stop services that you are receiving. For
example, you tnay ask for an appeal if we don't pay for a drug, item, or service you think you
should be able to receive. Chapter 9 explains appeals, including the process involved in making
an appeal.
Balance Billing — A situation in which a provider (such as a doctor or hospital) bills a patient
tnore than the plan's cost-sharing amount for services. As a metnber of our plan, you only ha�e
to pay the plan's cost-sharing amounts when you get services covered by our plan. We do not
allow providers to "balance bill" you. See Chapter 4, Section 1.4 for more information about
balance billing.
Benefit Period —The way that both our plan and Original Medicare measures your use of skilled
nursing facility (SNF) services. A benefit period begins the day you go into a skilled nursing
facility. The benefit period ends when you haven't received any skilled care in a SNF) for 60
days in a row. If you go into a skilled nursing facility after one benefit period has ended, a new
benefit period begins. Tl�ere is no limit to the number of benefit periods.
Brand Name Drug — A prescription drug that is manufactured and sold by the pharmaceutical
company that originally researched and developed the dt•ug. Brand name drugs have the same
active-ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until after the
patent on the brand name drug has expired.
Catastrophic Coverage Stage — The stage in the Part D D�ug Benefit where you pay a low
copayment or coinsurance for your drugs after you or other qualified parties on your behalf have
spent $4,75o in covei•ed drugs during the covel•ed year.
Centers for Medicare & Medicaid Services (CMS) — The federal agency that administers
Medicare. Chapier 2 explains how to contact CMS.
Coinsurance — An amount you may be required to pay as your share of the cost for services or
prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (foi•
example, 20%).
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Chapter 12: Definitions of important words
is personal care that can be provided by people who don't have professional skills or training,
such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed
or chair, moving around, and using the bathroom. It may also include the kind of health-related
care that most people do themselves, lilce using eye drops. Medicare doesn't pay for custodial
care.
Deductible — The amount (if applicable) you must pay for health care or prescriptions before our
plan begins to pay.
Disenroll or Disenrollment — The process of ending your membership in our plan.
Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Dispensing Fee — A fee charged each time a covered d1•ug is dispensed to pay for the cost of
filling a prescription. The dispensing fee covers costs such as the pharmacist's time to prepare
and package the prescription.
Durable Medical Equipment — Certain medical equipment that is ordered by your doctor for
use at home. Examples are walkers, wheelchairs, or hospital beds.
Emergency — A medical emergency is when you, or any other prudent layperson with an
average lcnowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injuty, severe pain, or a medical condition that is
quickly getting worse.
Emergency Care — Covered services that are: 1) rendered by a provider qualified to furnish
emergency services; and 2) needed to evaluate or stabilize an emergency medical condition.
Evidence of Coverage (EOC) and Disclosure Information — This document, along with your
enrollment form and any other attachments, ridet•s, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Exception — A type of coverage determination that, if approved, allows you to get a drug that is
not on your plan sponsor's formulary (a formulaiy exception), or get a non-preferred drug at the
preferred cost-shai•ing level (a tiering exception). You may also request an exception if your plan
sponsor requires you to try another drug before receiving the drug you are requesting, or the plan
limits the quantity or dosage of the drug you are requesting (a formulary exception).
Extra Help — A Medicare program to help people with limited income and resources pay
Medicai•e prescription drug program costs, such as premiums, deductibles, and coinsurance.
Generic Drug — A prescription drug that is approved by the Food and Drug Administration
(FDA) as having the same active ingredient(s) as the brand name drug. Generally, a"generic"
drug works the same as a brand name drug and usually costs less.
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Chapter 12: Definitions of important words
Medicaid (or Medical Assistance) — A joint federal and state program that helps with medical
costs for some people with low incomes and limited resources. Medicaid programs vary fi•om
state to state, but most health care costs are covered if you qualify for both Medicare and
Medicaid. See Addendum A for information about how to contact Medicaid in your state.
Medically Accepted Indication — A use of a drug that is either approved by the Food and Drug
Administration or supported by certain reference books. See Chapter 5, Section 4 for more
information about a medically accepted indication.
Medically Necessary — Services, supplies, or drugs that are needed for the prevention, diagnosis,
or treatment of your medical condition and meet accepted standards of inedical practice.
Medicare — The federal health insurance program for people 65 years of age or oldet•, some
people under age 65 with certain disabilities, and people with End-Stage Renal Disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant). People
with Medicare can get theu• Medicare health coverage through Original Medicare, a Medicare
Cost Plan, (where available) a PACE plan, (where available) or a Medicare Advantage Plan.
Medicare Advantage Disenrollment Period — A set time each year when members in a
Medicare Advantage plan can cancel their plan enrollment and switch to Original Medicare. The
Medicare Advantage Disenrollment Period is fi�om January 1 until Februaiy 14, 2013.
Medicare Advantage (MA) Plan — Sometimes called Medicare Part C. A plan offered by a
private company that contracts with Medicare to provide you with all your Medicare Pat•t A and
Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service
(PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. When you are enrolled in a
Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for
under Original Medicare. In most cases, Medicar•e Advantage Plans also offer Medicare Part D
(prescription drug coverage). These plans are called Medicare Advantage Plans with
Prescription Drug Coverage. Eveiyone who has Medicare Part A and Part B is eligible to join
any Medicare health plan that is offered in their area, except people with End-Stage Renal
Disease (unless certain exceptions apply).
Medicare Cost Plan — A Medicare Cost Plan is a plan operated by a Health Maintenance
Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbutsed
contract under section 1876(h) of the Act.
Medicare Coverage Gap Discount Program — A program that provides discounts on most
covered Part D bi•and name drugs to Part D enrollees who have reached the Coverage Gap Stage
and who are not ah•eady receiving "Extl•a Help." Discounts are based on agreements between the
fedei•al government and certain drug manufacturer�s. For this reason, most, but not all, brand
natne drugs are discounted.
Medicare-Covered Services — Services covered by Medicare Part A and Part B. All Medicare
health plans, including our plan, must cover all of the services that are covered by Medicare Part
A and B.
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Chapter 12: Defnitioils of important words
Original Medicare ("Traditional Medicare" or "Fee-for-service" Medicare) — Original Medicare
is offered by the government, and not a private health plan such as Medicare Advantage Plans
and prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care provideis payment amounts established by Congress.
You can see any doctor, hospital, or other health care provider that accepts Medicare. You must
pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your
share. Original Medicare has two parts: Part A(Hospital Insurance) and Part B(Medical
Insurance) and is available everywhere in the United States.
Out-of-Network Pharmacy — A pharmacy that doesn't have a contract with our plan to
coordinate or provide covered drugs to members of our plan. As explained in this Evidence of
Coverage, most drugs you get from out-of-network pharmacies are not covered by our plan
unless certain conditions apply.
Out-of-Networlc Provider or Out-of-Network Facility — A provider or facility with which we
have not arranged to coordinate or provide covered services to members of our plan. Out-of-
networlc providers are providers that are not employed, owned, or operated by our plan or are not
under contract to deliver covered services to you. Using out-of-network providers or facilities is
explained in this booklet in Chapter 3.
Out-of-Pocket Costs — See the definition for "cost sharing" above. A member's cost-sharing
requu•ement to pay for a portion of services or drugs received is also referred to as the member's
"out-of-pocket" cost requirement.
PACE plan — A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical,
social, and long-term care seivices for frail people to help people stay independent and living in
their community (instead of moving to a nursing home) as long as possible, while getting the
high-quality care they need. People enrolled in PACE plans receive both their Medicare and
Medicaid benefits through the plan.
Part C— see "Medicare Advantage (MA) Plan."
Part D— The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we
will refer to the prescription drug benefit program as Part D.)
Part D Drugs — Drugs that can be covered under Part D. We may or may not offer all Part D
drugs. (See your formulary for a specific list of covered drugs.) Certain categories of dtugs were
specifically excluded by Congress fi•om being covered as Part D drugs.
Preferred Providei- Ot�ganization (PPO) Plan — A Pi•eferred Pi•ovider Organization plan is a
Medicare Advantage Plan that has a network of contracted provideis that have agreed to treat
plan members for a specified payment amount. A PPO plan must cover all plan benefits whether
they are received fron� network oi• out-of-netwoi•Ic providei•s. PPO plans have an annual limit on
your out-of-pocket costs for services received fi•om network (preferred) providers and a higher
GRP 12 225 D 174 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna Medicat•esM Plan (PPO)
Chapter 12: Deiinitions of itnportant words
Period include: if you move outside the service area, if you are getting "E�tra Help" with your
prescription drug costs, if you move into a nursing home, if we violate our contract with you, ot•
if you are a member of our plan through an employer/union/ trust group retiree plan.
Special Needs Plan — A special type of Medicare Advantage Plan that provides more focused
health care for specific groups of people, such as those who have both Medicare and Medicaid,
who reside in a nut•sing home, or who have certain cht�onic medical conditions.
Step Therapy — A utilization tool that requires you to first tiy another drug to treat your medical
condition before we will cover the drug your physician tnay have initially prescribed.
Supplemental Security Income (SSI) — A monthly benefit paid by Social Security to people
with limited income and resources who are disabled, blind, or age 65 and older. SSI beneiits are
not the same as Social Security benefits.
Urgently Needed Care — Urgently needed care is care provided to treat a non-emergency,
unforeseen medical illness, injury, or condition that requires immediate medical care.
GRP 12 225 D 176 PPO ESA EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
State Health Insurance Arizona State Health Insurance Assistance Program
Assistance Program DES Division of Aging and Adult Services
1789 W. Jefferson St. (Site Code 950A)
Phoenix, AZ 85007
Phone: 602-542-4446/800-432-4040
www. azdes. gov/aaa/program s/sh i p
State Medical Assistance Health Care Cost Containtnent of Arizona
Office 801 E. Jefferson Street, MD 4100
Phoenix, AZ 85034
Phone: 602-417-7000/800-654-8713
http://www.ahcccs. state. az. us
Arkansas
Quality Improvetnent Arkansas Foundation for Medical Care
Organization 1020 West 4th Street, Suite 200
Little Rock, AR 72201
Phone: 501-212-8600 / 800-272-5528
www.afmc.org
State Health Insurance Seniar Health Insurance Information Program (SHIIP)
Assistance Program Arkansas Insurance Department
1200 West Third Street
Little Rock, AR 72201
Phone: 501-371-2782 / 800-224-6330
http://insurance. arlcansas.gov/seniors/ho mepage.htm
State Medical Assistance Department of Human Services of Arkansas
Office Donaghey Plaza South
P. O. Box 1437, Slot 5401
Little Rock, AR 72203-1437
Phone: 501-682-8233 / 800-482-5431
http://www.medicaid state ar.us/
California
Quality Impt•ovement Health Services Advisory Group
Organization 700 North Brand Boulevard, Suite 300
Glendale, CA 91203
Phone: 866-800-8749
TTY: 800-881-5980
www.hsag.com
State Health Insurance California Health Insurance Counseling & Advocacy Program
Assistance Program (HICAP)
Department of Aging
1300 National Drive
Sacramento, CA 95834
Phone: 800-434-0222
www.aging.ca.gov/HICAP
State Medical Assistance California Departnlent of Health Seivices
Office 1501 Capitol Avenue, MS 4604
Sacramento, CA 95814
GRP 12 225 D 178 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
State Pharmaceutical ConnPACE - Connecticut Department of Social Services
Assistance Program P.O. Box 5011
Hartford, CT 06102
Phone: 860-269-2029/800-423-5026
//www.connpace.com/
Delaware
Quality Improvement
Organization
State Health Insurance
Assistance Program
State Medical Assistance
Office
State Pharmaceutical
Assistance Program
District of Columbia
Quality Insights of Delaware
Baynard Bldg. Suite 100
3411 Silverside Road
Wilmington, DE 19810-4812
Phone: 302-478-3600 / 866-475-9669
http://www.wvmi. org/corp/
ELDERinfo
841 Silver Lake Blvd
Dovet•, DE 19904
Phone: 302-674-7364 / 800-336-9500
http://delawareinsurance. gov/department
Delaware Health and Social Services
1901 N. Du Pont Highway, Lewis Bldg.
New Castle, DE 19720
Phone: 302-255-9500/800-372-2022
www. state.de.us/dhss
Chronic Renal Disease Program
11-13 Church Ave.
Milford, DE 19963
Phone: 302-424-7180 / 800-464-4357
httn: //www. dhss.delaware. gov/dhss/dmr
Ider/eldindex.shtml
.html
Quality Improvement Delmarva Foundation for Medical Care, Inc.
Organization 9240 Centreville Road
Easton, MD 21601
Phone: 202-293-9650 / 800-937-3362
www. de lmarvafoundation. org
State Health Insurance Health Insurance �Counseling Project (HICP)
Assistance Program 441 4th Street, NW Suite 900 South
Washington, DC 20001
Phone: 202-739-0668
TTY: 202-724-8925
htta: //dcoa.dc. gov/dcoa.s ite/default. asp
State Medical Assistance DC Healthy Family
Office 899 North Capitol Street, NE
Washington, DC 20002
Phoue: 202-724-5506 / 888-557-1 ll6
www.doh.dc.gov __.
Floi•ida
Florida Medical Quality Assurance
GRP 12 225 D 180 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
Office 1390 Miller Street, Room 209
Honolulu, HI 96813
Phone: 808-524-3370 / 800-316-8005
httn://www. med-quest.us/
State Pharmaceutical
Assistance Program
Idaho
Quality Improvement
Organization
Hawaii State Pharmacy Assistance Program
P.O. Box 700220
Kapolei, HI 96709
Phone: 808-692-7999/866-878-9769
http://www.med-quest.us/eligibilityBligPrograms_SPAP.html
Phone: 208-343-4617 / 800-488-1118
www.QualisHealthMedicare.org
Qualis Health
720 Park Blvd., #120
Boise, ID 83712
State Health Insurance Senior Health Insurance Benefits Advisors (SHIBA)
Assistance Program 700 West State Street, P.O. Box 83720
Boise, ID 83720-0043
Phone: 208-334-4352/800-247-4422
www.doi.idaho.gov _
State Medical Assistance
Office
Idaho Departtnent of Health and Welfare
P.O. Box 83720
Boise, ID 83720-0036
Phone: 208-334-6700 / 800-926-2588
healthandwelfare. idaho . gov
State Pharmaceutical Idaho AIDS Drug Assistance Program (IDAGAP) - Department
Assistance Program of Health and Welfare
P. O. Box 83720
Boise, ID 83720
Phone: 208-334-5943/800-926-2588
http://healthandwelfare. idaho. gov/Health/Fami lyPlanningSTDHI
V/HIVCareandTreatment/tabid/391 /Default.aspx
Illinois
Quality Improvement Illinois Foundation for Quality Health Care
Organization 711 Jorie Blvd., Suite #301
Oak Brook, IL 60523-4425
Phone: 630-928-5800 / 800-647-8089
www.ifmc-il.org
State Health Insurance Senior Health Insurance Pi•ogram (SHIP)
Assistance Program 320 West Washington St.
Springfield, IL 62767-0001
Pl�one: 217-785-9021 / 800-548-9034
TTY: 217-524-4872
httn://insurance.illinois.gov/SHIP/
State Medical Assistance Illinois Department of Healthcare and Family Services
Office 201 South Grand Avenue East
GRP 12 225 D 182 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendwn A
__.__.
Office P. O. Box 36510
Des Moines, IA 50315
Phone: 515-256-4606/800-338-8366
www.dhs.state.ia.us
Kansas
Quality Improvement
Organization
Kansas Foundation for Medical Care
2947 SW Wanamaker Dt•ive
Topeka, KS 66614-4193
Phone: 785-273-2552/800-432-0770
www.kfmc.org
State Health Insurance Senior Healtl� Insurance Counseling for Kansas (SHICK)
Assistance Program 503 S. Kansas Avenue
Topeka, KS 66603
Phone: 316-337-7386 / 800-432-3535
www.agin�xausa�.u��
State Medical Assistance Department of Social and Rehabilitation Services of Kansas
Office 915 Southwest Harrison Street
Topeka, KS 66612
Phone: 785-296-3981/800-766-9012
TTY: 785-296-1491
httn://www. siskansas.org/hcp/
Quality Improvement
Organization
State Health Insurance
Assistance Program
State Medical Assistance
Office
Louisiana
Quality Improvement
Organization
State Health Insurance
Assistance Progratn
Health Care Excel, Inc.
2629 Waterfi�ont Parkway East Drive, Suite 150
Indianapolis, IN 46214
Phone: 317-347-4500 / 800-288-1499
www.hce.org
State Health Insurance Assistance Pt•ogram (SHIP)
275 E. Main St., 3E-E
Frankfort, KY 40621
Phone: 502-564-6930/877-293-7447
TTY: 888-642-1137
http://www.chfs.ky.gov/dail/ship.htm
Cabinet for Health Services of Kentucky
275 E. Main St.
Franicfort, KY 40621
Phone: 502-564-4321/800-635-2570
www.chfs.ky.gov
Louisiana Health Care Review
8591 United Plaza Blvd., Suite 270
Baton Rouge, LA 70809
Phone: 225-926-6353/800-433-4958
www.lhcr.org
Senioi• Health Insui•ance Information Program (SHIIP)
P.O. Box 94214
GRP 12 225 D 184 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
State Medical Assistance Departtnent of Health and Mental Hygiene
Office 201 West Preston Street
Baltimore, MD 21201
Phone: 410-767-5800 / 800-492-5231
www.dhmh.state.md.us
State Pharmaceutical Matyland Senior Prescription Drug Assistance Program - c/o
Assistance Program Pool Administrators
628 Hebron Avenue, Suite 212
Glastonbury, CT 06033
Phone: 800-551-5995
TTY: 800-877-5156
Massachusetts
Quality Improvement
Organization
://marylandspdap.com
MassPRO
245 Winter St.
Waltham, MA 02451-1231
Phone: 781-890-0011/800-252-5533
www.masspr�.ur�
State Health Insurance Serving Health Information Needs of Elders (SHINE)
Assistance Program One Ashburton Place, Sth Floor
Boston, MA 02108
Phone: 617-727-7750/800-243-4636
www.800ageinto.com
State Medical Assistance Office of Health and Human Services of Massachusetts
Office One Ashburton Place, l lth Floor
Boston, MA 02108
Phone: 617-573-1600 / 800-841-2900
www.tnass. gov/masshealth
State Pharmaceutical Massachusetts Prescription Advantage
Assistance Program P.O. Box 15153
Worcester, MA 01615
Phone: 800-243-4636
TTY: 877-610-0241
http://www.mass.gov/?pageID=eldersterminal&L=3 &LO=Home
&L 1=Health+Care&L2=Prescription+Advantage&sid=Eelders&
b=terminalcontent&f=pa overview&csid=Eelders
Michigan
Quality Impi•ovement
Organization
State Health Insui•ance
Assistance Program
Michigan Peer Review Organization
22670 Haggerty Road, Suite 100
Farmington Hills, MI 48335-2611
Phone: 248-465-7300 / 800-365-5899
www.mpro.org
MMAP, Inc.
6105 West St. Joseph, Suite 204
Lansing, MI 48917-4850
Phone: 500-803-7174
GRP 12 225 D 186 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
http:Uwww.primaris.org/
State Health Insm�ance
Assistance Progratn
State Medical Assistance
Office
State Pharmaceutical
Assistance Program
Montana
Quality Improvement
Organization
State Health Insurance
Assistance Program
CLAIM
200 N. Keene St.
Columbia, MO 65201
Phone: 573-817-8320 / 800-390-3330
www.missouriclaim.org
Department of Social Services of Missouri - MO HealthNet
Division
615 Howerton Court, P.O. Box 6500
Jeffet�son City, MO 65102-6500
Phone: 573-751-3425 / 800-392-2161
TTY: 800-735-2966
www.dss.mo.govhnhd/
Missouri Rx Plan
P.O. Box 6500
Jefferson City, MO 65102
Phone: 573-751-3425 / 800-375-1406
TTY: 800-735-2966
httn://morx.mo.gov/ _
Mountain-Pacific Quality Health Foundation
3404 Cooney Drive
Helena, MT 59602
Phone: 406-443-4020 / 800-362-5880
www.mpqnr.org
Montana State Health Insurance Assistance Program (SHIP)
2030 - 1 lth Ave
Helena, MT 59604-4210
Phone: 406-444-7870 / 800-551-3191
t,rr„•//�x��x�w �lnhhs.mt.�ov/sltc/services/aging/ship.shtml
State Medical Assistance Montana Department of Public Health & Human Services-
Office Division of Child and Adult Health Resources
2030 l lth Avenue
Helena, MT 59601
Phone: 800-362-8312
httn://www.dphhs.mt. gov
State Phai•maceutical Bridging the Gap
Assistance Progratn P.O. Box 202951, Cogswell Building C-211
Helena, MT 59620
Phone: 406-444-4744
http: //www. dphh s. mt. gov/PH S D/STD-HI V/std-h i v-
consorti.shtml
Nebraslca
Quality Improvement
Or�anization
Cimro of Nebraska
1230 O Street, Suite 120
GRP 12 225 D 188 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
_____. .
State Health Insurance NH SHIP - SeiviceLink Resource Center
Assistance Program 67 Water St., Suite 105
Laconia, NH 03246
Phone: 603-528-6945/866-634-9412
www.servicelinlc.org
State Medical Assistance New Hampshire Department of Health and Human Services
Office 129 Pleasant Street
Concord, NH 03301
Phone: 603-271-4344 / 800-852-3345
TTY: 800-735-2964
httn://www.dhhs.state.nh.us _
New Jersey
Quality Improvement Health Care Qualrty Strategies
Organization 557 Cranbury Road, Suite 21
East Brunswicic, NJ 08816
Phone: 732-238-5570 / 800-624-4557
TTY: 877-486-8048
www.hqsi.org
State Health Insurance State Health Insurance Assistance Pt•ogram (SHIP)
Assistance Program P. O. Box 360
Trenton, NJ 08625-0360
Phone: 877-222-3737 / 800-792-8820
www. state.nj .us/health/senior/ship. shtml
State Medical Assistance Department of Human Services of New Jersey
Office P.O. Box 712
Trenton, NJ 08625-0712
Phone: 800-356-1561
www.state.nj .us/hutnanservices/dmahs
State Pharmaceutical New Jersey Division of Medical Assistance and Health Setvices
Assistance Program Quakerbridge Plaza, P.O. Box 712
Trenton, NJ 08625
Phone: 800-356-1561
http://www.state.nj .us/humanservices/dmahs/index.html
New Mexico
Quality Improvement
Organization
State Health Insurance
Assistance Program
State Medical Assistance
New Mexico Medical Review Association
5801 Osuna Road NE, Suite 200
Albuquerque, NM 87109
Phone: 505-998-9898/800-663-6351
www.nmmra.oi•
Benefits Counseling Program
2550 Cerrillos Road
Santa Fe, NM 87505
Phone: 505-476-4846/800-432-2080
TTY: 800-659-8331
www.nmaging.state.nm.us
T�enartment of Human Services of New Mexico
GRP 12 225 D 190 PPO ESA EOGwith Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
TTY: 919-733-4851
www.dhhs.state.nc.us/dma/mqb.html
State Pharmaceutical
Assistance Program
North Dakota
Quality Improvement
Organization
State Health Insurance
Assistance Program
State Medical Assistance
Office
Phone: 919-733-7301 / 877-466-2232
httn: //www. epi.state. nc.us/ep i/hiv/adap.htm 1
North Carolina HN SPAP
1902 Mail Selvice Center
Raleigh, NC 27699
North Dakota Health Care Review, Inc.
800 31st Avenue SW
Minot, ND 58701
Phone: 701-852-4231 / 888-472-2902
www.ndhcri.ot�g
Senior Health Insurance Counseling (SHIC)
600 E. Boulevard Ave.
Bismarck, ND 58505-0320
Phone: 701-328-2440 / 800-247-0560
TTY: 800-366-6888
http://www. state.nd.us/ndins/
Dept of Human Services of North Dakota - Medical Services
600 E Boulevard Ave, Dept 325
Bismarck, ND 58505-0250
Phone: 701-328-2321 / 800-755-2604
www.nd.gov/dhsl _
Ohio
Quality Improvement Ohio KePRO, Inc.
Organization Rock Run Center, Suite 100
5700 Lombardo Center Dr.
Seven Hills, OH 44131
Phone: 216-447-9604 / 800-589-7337
State Health Insurance
Assistance Program
State Medical Assistance
Office
Ol�lahoma
Quality Improvement
www.ohiokepro.com
Ohio Senior Health Insurance Information Program (OSHIIP)
50 W. Town Street, Third Floor - Suite 300
Columbus, OH 43215
Phone: 614-644-3458 / 800-686-1578
TTY: 614-644-3745
www. insurance.ohro.gov
Departtnent of Job and Family Services of Ohio - Ohio Health
Plans
50 West Town Street
Columbus, OH 43215
Phone: 614-644-0140 / 800-324-8680
htt�://ifs.ohio.�ov/ohp _
Oklahoina Foundation for Medical Quality, Inc.
14000 Quail Springs Parkway, Suite 400
GRP 12 225 D 192 PPO ESA EOGwitl� Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
Phone: 800-692-7462
State Pharmaceutical
Assistance Program
www.dpw.state.pa.us
Department of Public Welfare Special Pharmaceutical Benefits
Progratn
P.O. Box 8021
Harrisburg, PA 17105
Phone: 800-922-9384
http://www.dpw. state. pa.us/foradults/healthcaremedicalass istanc
e/aidswaiverprogram/specialpharmaceuticalbenefitspt•ogram/ind
ex. hhn
Rhode Island
Quality Improvement Rhode Island Quality Partners, Inc.
Organization 235 Promenade Street, Suite 500, BoY 18
Providence, RI 02908
Phone: 401-528-3200 / 800-662-5028
State Health Insurance
Assistance Program
State Medical Assistance
Office
WWW.Ylaualltiypdr�[lcr�.vi �
Senior Health Insurance Program (SHIP)
74 West Road, Hazard Bldg.
Cranston, RI 02920
Phone: 401-462-4444
TTY: 401-462-0740
http://adre.ohhs.ri. gov
Department of Human Services of Rhode Island
206 Eltnwood Avenue
Providence, RI 02907
Phone: 401-462-5300
www.dhs.ri.gov
State Pharmaceutical Rhode Island Pharmaceutical Assistance for the Elderly (RIPAE)
Assistance Program - Attention RIPAE Rhode Island Department of Elderly Affairs
74 West Road, Hazard Building, Second Floor
Cranston, RI 02920
Phone: 401-462-3000
TTY: 401-462-0740
://www.dea. state.ri.us/progt�ams/prescription_assist.
South Carolina
Quality Improvement
Organization
Carolina Center for Medical Excellence
246 Stoneridge Drive, Suite 200
Columbia, SC 29210
Phone: 803-251-2215/800-922-3089
www.thecarolinascenter.org
State Health Insurance (I-CARE) Insurance Counseling Assistance and Referrals for
Assistance Program Ekleis
1301 Gervais Street, Suite 350
Colutnbia, SC 29201
Phone: 803-734-9900 / 800-868-9095
www.a�in�.sc.
GRP 12 225 D 194 PPO ESA EOC-witli Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
www.tm£org
State Health Insurance Health Information Counseling and Advocacy Program (HICAP)
Assistance Program P.O. Box 149030
Austin, TX 78714-9030
Phone: 512-438-3011 / 800-252-9240
www.dads.state.�.us
State Medical Assistance Health and Human Services Comtnission of Texas
Office 4900 N. Lamar Blvd.
Austin, TX 78751-2316
Phone: 512-424-6500/800-252-8263
http://www.hhsc. state.�. us
State Pharmaceutical Texas HIV State Pharmacy Assistance Program (SPAP)
Assistance Program P.O. Box 149347 ATT`N: MSJA-MC 1873
Austin, TX 78714
Phone: 800-255-1090
httn ://www. dshs. state.�.us/hivstd/meds/sp ap. shtm
Utah
Quality Improvement
Organization
HealthInsight
348 E. 4500 S., Suite 300
Salt Lake City, UT 84107
Phone: 801-892-0155 / 800-748-6773
www.neaitnmsign�.ur�
State Health Insurance Senior Health Insurance Informat'ron Program (SHIP)
Assistance Program 195 North 1950 West
Salt Lake City, UT 84116
Phone: 801-538-3910 / 877-424-4640
http://www.hsdaas.utah.gov/insurance_programs. htm
State Medical Assistance Utah Department of Health
Office P.O. Box 143106
Salt Lake City, UT 84114-3106
Phone: 801-538-6155 / 800-662-9651
http://health.utah.gov/medicaid/
Vermont
Quality Improvement Northeast Health Care Quality Foundation
Organization 15 Old Rollinsford Rd., Suite 302
Dover, NH 03820
Phone: 603-749-1641 / 800-772-0151
TTY: 877-486-2048
www.nncql.�r�
State Health InsLirance State Health Insurance Assistance Program (SHIP)
Assistance Program 481 Summer Street, Suite 101
St. Johnsbury, VT 05819
Phone: 802-748-5182 / 800-642-5119
http://www.medicarehelpvt.net/
State Medical Assistance
of Human Services of Vermont
GRP 12 225 D 196 PPO ESA EOC-witli Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Addendum A
_ ._
Assistance Progt�am P.O. Box 40256
Olympia, WA 98504-0256
Phone: 800-562-6900
TTY: 360-586-0241
://www. insurance.wa.
State Medical Assistance
Office
State Pharmaceutical
Assistance Program
West Virginia
Quality Improvement
Organization
State Health Insurance
Assistance Program
State Medical Assistance
Office
Wisconsin
Quality Improvement
Organization
State Health Insurance
Assistance Program
State Medical Assistance
Department of Social and Health Services of Washington
Office Building Two
14th and Jefferson Street
Olympia, WA 98504
Phone: 800-562-3022
www.adsa.dshs.wa:gov
Washington State Health Insurance Pharmacy Assistance
Program
P.O. Box 1090
Great Bend, KS 67530
Phone: 800-877-5187
https://www.wship.org�
West Virginia Medical Institute, Inc.
3001 Chesterfield Avenue
Charleston, WV 25304
Phone: 304-346-9864 / 800-642-8686
www.wvmi.org
West Virginia State Health Insurance Assistance Program (WV SI�P)
1900 Kanawha Blvd. East
Charleston, WV 25305
Phone: 304-558-3317 / 877-987-4463
www.wvship.org
West Virginia Department of Health & Human Resources
350 Capitol Street, Room 251
Cliarleston, WV 25301
Phone: 304-558-1700/800-642-8589
httn ://www. dhhr.wv. g ov/b m s/
MetaStar, Inc.
2909 Landmark Place
Madison, WI 53713
Phone: 608-274-1940 / 800-362-2320
www.metastar.com
Wisconsin SHIP (SHIP)
1 West Wilson Street
Madison, WI 53703
Phone: 608-267-3201 / 800-242-1060
TTY: 888-701-1251
www.dhfs. state.wi.us/aging/SHIP.htm
Wisconsin Department of Health
GRP 12 225 D 198 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Multi-language Interpreter Services
Multi-language Interpreter Services
English: We have free interpreter setvices to answej• any questions you may have about our
health or drug plan. To get an interpreter, just call us at 1-888-267-2637. Someone who speaks
English/Language can help you. This is a free service.
Spanish: Tenemos servicios de interprete sin costo alguno para responder cualquier pregunta
que pueda tener sobre nuestro plan de salud o medicamentos. Para hablat• con un interprete, por
favor Ilame al 1-888-267-2637. Alguien que hable espanol le podra ayudar. Este es un servicio
gratuito.
Chinese Mandarin: ��17�'���������� � ��%� A����'°���'��1'�`��1����
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Chinese Cantonese:
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Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang
mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha
ng tagasaling-wika, tawagan lamang kami sa 1-888-267-2637. Maaari kayong tulungan ng isang
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interpretation pour repondre a toutes vos
questions relatives a notre regime de sante ou d'assurance-medicaments. Pour acceder au service
d'interpretation, il vous suffit de nous appeler au 1-888-267-2637. Un interlocuteur parlant
Fran�ais pourra vous aider. Ce seivice est gratuit.
Vietnamese: Chung toi co dich vu thong dich mien phi c�e tra lo�i cac cau hoi ve chuo'ng su'c
klloe va chuo'ng trinh thuoc men. Neu qui vi can thong dich vien xin goi 1-888-267-2637. se co
uhan vien noi tieng Viet giup c�o� qui vi. �ay 1'a dich vu mien phi .
German: Unser kostenloser polmetscherservice beantwortet Ihren Fragen zu unserem
Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-888-672-2637.
Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
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GRP 12 225 D 200 PPO ESA EOC-with Rx (Y2013)
2013 Evidence of Coverage for Aetna MedicareSM Plan (PPO)
Multi-language Interpreter Services
_._ ____..
Notes
GRP 12 225 D 202 PPO ESA EOC-witli R� (Y2013)
Aetna Medicares`` Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
AETNA LIFE INSURANCE COMPANY
EXHIBIT C
Contract Holder Name: City Of Fort Worth
Conh•act Holder Group Agreement Effective Date: January 1, 2013
Contract Holder Number: 411868
This Medical Benefits Chart is part of the Evic�ence of Coverage for Aetna Medicare Plan (PPO).
When the Evidence of Coverage refers to the attachment for information on health care benefits
covered under our plan, it is referring to this Medical Benefits Chart. (See Chapter 4, Medical
Benefits Chart (what is covered and what you pay).
Annual Deductible
This is the amount you have to pay out of pocket before the $�
plan will pay its share for your covered medical services.
Annual Maximum Out-of-Pocket Limit
The maximum out-of-pocket limit applies to In-network maximum out-of-pocket amount:
all covered Medicare benefits including $0
deductible
Combined maximum out-of-pocket amount
(in- and out-of-network): $0
GRP 12 224/225 D H4524 1 ME PPO_ESA SCH COPAY (Y2013)
Aetna Medicares"' Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
nearest appropr'rate facility that can provide care if
they are furnished to a member whose medical
condition is such that other means of transpot•tation
are contraindicated (could endanger the person's
health) or if authorized by the plan. The member's
condition must require both the ambulance
transportation itself and the level of service provided
in order for the billed service to be considered
medically necessary.
• Non-emergency transportation by ambulance is
appropriate if it is documented that the member's
condition is such that other means of transportation
are contraindicated (could endanger the person's
health) and that transportation by ambulance is
medically required.
• Round trip transport applies for each Medicare-
covered ambulance transport to a physician office or
dialysis visit.
*Prior authorization rules apply for air ambulance transfers
and non-emergency transportation by ground ambulance or
medical van.
Y
Annual wellness visit
If you've had Part B for longer than 12 months, you can get
an annual wellness visit to develop or update a petsonalized
prevention plan based on your current health and risk
factors. This is covered once every 12 months.
Note: Your fii•st annual wellness visit can't talce place
within 12 months of your "Welcome to Medicare"
preventive visit. However, you don't need to have had a
"Welcome to Medicare" visit to be covered for annual
welluess visits after you've had Part B for 12 months.
$0 copay for each Medicare-
covered ambulance benefit
(one way)
There is no coinsurance,
copayment, or deductible for
the annual wellness visit.
GRP 12 224/225 D H4524 3 ME PPO ESA SCH COPAY (Y2013)
Aetna MedicareS"' Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
, ; What you must pay (after
Services that are covered for you deductible) when you get
these services
appropriate), check your blood pressure, and give you tips
to make sure you're eating well.
� Cardiovascular disease testing
Blood tests for the detection of cardiovascular disease (or
abnormalities associated with an elevated risk of
cardiovascular disease) once every 5 years (60 months).
Cervical and vaginal cancer screening
Covered services include:
• For all women: Pap tests and pelvic exams are
covered once evety 12 months
Chiropractic services
Covered seivices include:
$0 copay
$0 copay
$0 copay per
covered visit
Medicare-
We cover only manual manipulation of the spine to
correct subluxation
�
Colorectal cancer screening
For people 50 and older, the following are covered:
• Flexible sigmoidoscopy (or screening barium enema
as an alternative) every 48 months
• Fecal occult blood test, every 12 months
$0 copay
For people at high rislc of colorectal cancet•, we cover:
• Screening colonoscopy (or screening barium enema
as an alternative) every 24 tnonths
GRP 12 224/225 D H4524 5 ME PPO_ESA SCH COPAY (Y2013)
Aetna Medicares"' Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
• For people with diabetes who have severe diabetic
foot disease: One pair pei� calendar year of
therapeutic custom-molded shoes (including inserts
provided with such shoes) and two additional pairs
of inserts, or one pau• of depth shoes and three pairs
of inserts (not including the non-customized
removable inserts provided with such shoes).
Coverage includes fitting.
Diabetes self-management training is covered under
certain conditions
Durable medical equipment and related suppliesX
(For a definition of "durable medical equipment," see
Chapter 10 of this booklet.)
Covered items include, but are not limited to: wheelchairs,
crutches, hospital bed, IV infusion pump, oxygen
equipment, nebulizer, and walker.
We cover all medically necessary durable medical
equipment covered by Original Medicare. If our supplier in
your area does not cariy a particular brand or manufacturer,
you may ask them if they can special order it for you.
*Prior authorization rules apply for certain services; contact
Member Services for information.
Emergency care
$0 for each Medicare covered
item
Emergency care refers to services that are: 0% of the cost for each
• Furnished by a provider qualified to furnish Medicare-covered emergency
emergency setvices, and room visit
• Needed to evaluate or stabilize an emergency
medical condition. If you are immediately
admitted to the hospital, you
GRP 12 224/225 D H4524 7 ME PPO_ESA SCH COPAY (Y2013)
Aetna MedicareS�f Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
live better with chronic conditions like diabetes,
heart ailments, asthma, and low back pain.
• Telemonitoring for hypertension
This program is designed to help you manage your Included in your plan
high blood pressure. You will receive a free
automatic blood pressure monitor, education
material and support on how to control your blood
pressure.
Hearing services
• Diagnostic hearing and balance evaluations
performed by your provider to determine if you need
medical treatment are covered as outpatient care
when furnished by a physician, audiologist, or other
qualified pt•ovider.
• Our plan covers one routine hearing exam every 12
months
Hearing aid reimbutsement (A Statement of Satisfaction
Form must be signed by the member and the provider and
submitted to HMO to obtain reimbursement. Contact
Membei• Services to obtain this form.) Amounts you pay
for hearing aids do not count toward your annual maximum
out-of-pocleet amount.
Y
HIV screening
$0 for basic hearing
evaluations
$0 copay for one routine
hearing exam every 12 months
Our plan reimburses: $2,000
every 36 months
$0 copay
For people who ask for an HIV screening test or who are at
increased risk for HIV infection, we cover:
• One screening exam every 12 months
For women who are pregnant, we cover:
GRP 12 224/225 D H4524 9 ME PPO ESA SCH COPAY (Y2013)
Aetna Medicares"I plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
�,.� � �
What you must pay (after
Services that are covered for you deductible) when you get
these services `
the hospice program, yow� hospice provider will bill
Ot•iginal Medicare for the services that Original Medicare
pays for.
For services that are covered bv Medicare Part A or B and
are not related to vour terminal condition: If you need non-
emergency, non-urgently needed services that are covered
under Medicare Part A or B and that are not related to your
terminal condition, your cost for these seivices depends on
whether you use a provider in our plan's network:
• If you obtain the covered selvices from a network
provider, you only pay the plan cost-sharing amount
for in-networlc services
• If you obtain the covered services from an out-of-
network provider, you pay the cost sharing under
Fee-for-Service Medicare (Original Medicare).
However, after payment, you can ask us to pay you
back for the difference between the cost sharing in
our plan and the cost sharing under Original
Medicare.
For services that are covered by our plan but are not
covered by Medicare Part A or B: Our plan will continue to
cover plan-covered services that are not covered under Part
A or B whether or not they are related to your terminal
condition. You pay your plan cost shat•ing amount for these
services.
Note: If you need non-hospice care (care that is not related
to your terminal condition), you should contact us to
arrange the seivices. Getting your non-hospice care through
our networlc providers will lower your share of the costs for
the services.
Our plan covers hospice consultation services for a Included service in Inpatient
terminally ill petson who hasn't elected the hospice benefit. hospital care; Physician
Palliative care consultation is also available. services cost sharing applies
for outpatient consultations
GRP 12 224/225 D H4524 11 ME PPO_ESA SCH COPAY (Y2013)
Aetna MedicareS"I Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
.,
What you must pay (after
Services that are covered for you deductible) when you get
these services '
providers are willing to accept the Original
Medicare rate, then you can choose to obtain your
transplant services locally or at a distant location
offered by the plan. If our plan provides transplant
services at a distant location (outside of the service
area) and you chose to obtain transplants at this
distant location, we will arrange or pay for
appropriate lodging and transportation costs for you
and a companion. If you choose to obtain any
transplant services that are covered by our plan from
a Medicare-approved transplant center or facility
that does not participate in our plan's Institutes of
ExcellenceTM network, we will not arrange or pay
for lodging or transportation costs for you or your
companion. A complete list of Medicare-approved
transplant centers and facilities that participate in
our Plan's Institutes of Excellence network can be
found in the Provider Directory and on out• website
at www.aetnaretireeplans.com.
Blood - including storage and administration.
Coverage of whole blood and packed red cells
begins only with the fourth pint of blood that you
need — you must either pay the costs for the first 3
pints of blood you get in a calendar year or have the
blood donated by you or someone else. All other
components of blood are covered beginning with the
first pint used.
Physician services
Note: To be an inpatient, your provider must write an order
to admit you formally as an inpatient of the hospital. Even if
you stay in the hospital overnight, you might still be
considered an "outpatient." If you are not sure if you are an
inpatient or an outpatient, you should ask the hospital staff.
You can also �nd more information in a Medicare fact sheet
called "Are You a Hospital In�atient oi• Outpatient? If You
Have Medicat•e — Ask!" This fact sheet is available on the
GRP 12 224/225 D H4524 13 ME PPO_ESA SCH COPAY (Y2013)
Aetna MedicareS"` Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
`What you must pay (after '
Services that are covered for you deductible) when you get '
these services
artificial legs, arms, and eyes including adjustments,
repairs, and replacements required because of
breakage, wear, loss, or a change in the patient's
physical condition
Physical therapy, speech therapy, and occupational
therapy
� Medical nutrition therapy
This benefit is for people with diabetes, renal (kidney)
disease (but not on dialysis), or aftei• a kidney transplant
when referred by your doctor.
We cover 3 hours of one-on-one counseling services during
your first year that you receive medical nutrition therapy
services under Medicare (this includes our plan, any other
Medicare Advantage plan, or Original Medicare), and 3
hours each year after that. If your condition, treatment, or
diagnosis changes, you may be able to receive more hours
of treatment with a physician's referl•al. A physician must
prescribe these services and renew theu• referral yearly if
your treatment is needed into the next calendar year.
Medicare Part B prescription drugs
These drugs are covered under Part B of Original Medicare.
Members of our plan receive coverage for these drugs
through our plan. Covered drugs include:
• Drugs that usually aren't self-administered by the
patient and are injected or infused while you are
getting physician, hospital outpatient, or ambulatory
surgical center services
• Drugs you take using durable medical equipment
(such as nebulizers) that were authorized by the plan
• Clotting factors you give yotn�self by injection if you
have hemophilia
• Inimunosuppressive Drugs, if you were enrolled in
$0 copay
$0 per prescription or reiill
GRP 12 224/225 D H4524 15 ME PPO ESA SCH COPAY (Y2013)
Aetna Medicares�f Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
Laboratory tests
Home PT/INR monitoring is covered for chronic,
oral anticoagulation management for members on
warfarin with mechanical heart valves, chronic atrial
fibrillation, or venous thromboembolism (inclusive
of deep venous thrombosis and pulmonary
embolism). The monitor and the home testing are
covered for members who meet certain conditions
and when it is prescribed by a doctor treating their
condition.
Blood. Coverage begins with the fourth pint of
blood that you need — you must either pay the costs
for the first 3 pints of blood you get in a calendar
year or have the blood donated by you or someone
else. Coverage of storage and administration begins
with the first pint of blood that you need.
Other outpatient diagnostic tests
*Prior authorization rules apply for certain services; please
contact Member Services for information.
Outpatient hospital services
We cover medically-necessary services you get in the
outpatient department of a hospital for diagnosis or
treatment of an illness or injury.
visits for Medicare-covered
benefits
$0 for specialist visits for
Medicare-covered benefits
$0 for Medicare-covered
r•outine X-rays
$0 for Medicare-covered
diagnostic radiology and
complex imaging services
$0 for Medicare-covered lab
services
$0 for Medicare-covered
diagnostic procedures or tests
$0 for Medicare-covered
therapeutic radiology ser•vices
$0 copay for Medicare-
covered medical supply items
$0 for Medicare-covered
Home INR monitor/tests
$0 copay for blood after the
first 3 unreplaced pints�'
Your cost share is based on:
• the
tests/services/supplies
you receive
Covered services include: • the provider of the
• Services in an emergency department or outpatient tests/services/supplies
GRP 12 224/225 D H4524 17 ME PPO ESA SCH COPAY (Y2013)
Aetna Medicares"' Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
Outpatient rehabilitation services
Covered services include: physical therapy, occupational
therapy, and speech language therapy.
Outpatient rehabilitation services are pt•ovided in various
outpatient settings, such as hospital outpatient depai�tments,
independent therapist ofiices, and Comprehensive
Outpatient Rehabilitation Facilities (CORFs).
Outpatient substance abuse services
Outpatient surgery*, including services provided at
hospital outpatient facilities and ambulatory surgical
centers
Note: If you are having surgery in a hospital, you should
checic with your provider about whether you will be an
inpatient or outpatient. Unless the provider writes an order
to admit you as an inpatient to the hospital, you are an
outpatient and pay the cost-sharing amounts for outpatient
surgery. Even if you stay in the hospital overnight, you
might still be considered an "outpatient."
*Prior authorization rules apply for certain services; contact
Member Services for information.
$0 for Medicare-covered
outpatient rehabilitation
service visit
$0 for Medicare-covered
individual or gt•oup therapy
visits
Your cost share is based on:
- the tests/services/supplies
you receive
- the provider of the
tests/services/supplies
- the setting where the
tests/services/supplies are
performed.
If you receive multiple
services in one visit, you
generally pay only the cost
sharing of the highest-cost
service.
$0 for Medicare-covered
outpatient hospital facility
visits
$0 for ambulatory surgical
centet• visits
GRP 12 224/225 D H4524 19 ME PPO_ESA SCH COPAY (Y2013)
Aetna MedicareS"f Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
Services that are covered for you
Podiatry services
Covered seivices include:
• Diagnosis and the medical or surgical treatment of
injuries and diseases of the feet (such as hammer toe
or heel spurs).
• Routine foot care for members with certain medical
conditions affecting the lower limbs
Prostate cancer screening exams
For men age 50 and older, covered services include the
following - once every 12 months:
• Digital rectal exam
• Prostate Specific Antigen (PSA) test
Prosthetic devices and related supplies*
Devices (other than dental) that replace all or part of a body
part or function. These include, but are not limited to:
colostomy bags and supplies directly related to colostomy
care, pacemakers, braces, prosthetic shoes, artificial limbs,
and breast prostheses (including a surgical bt�assiere after a
mastectomy). Includes certain supplies related to prosthetic
devices, and repair and/or replacement of prosthetic
devices. Also includes some coverage following cataract
removal or catai•act surgeSy — see "Vision Care" later in this
section for more detail.
*Prior authorization rules apply for certain services; please
contact Member Services for information.
Pulmonary rehabilitation services
What you must pay (after
deductible) when you get
these services
$0 copay for each Medicare-
covered visit
$0 copay
$0 for each Medicare covered
item
Comprehensive programs of pulmonary rehabilitation are �$0 for Medicare-covered
GRP 12 224/225 D H4524 21 ME PPO ESA SCH COPAY (Y2013)
Aetna Medicares°' Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
Services to treat kidney disease and conditions*
Covered services include:
• Kidney disease education services to teach kidney
care and help members make informed decisions
about theu• care. For members with stage IV chronic
kidney disease when referred by their doctor, we
cover up to six sessions of kidney disease education
services per lifetitne.
• Outpatient dialysis treatments (including dialysis
treatments when temporarily out of the service area,
as explained in Chapter 3)
• Inpatient dialysis tt•eatments (if you are admitted as
an inpatient to a hospital for special care)
• Self-dialysis training (includes training for you and
anyone helping you with your home dialysis
treatments)
• Home dialysis equipment and supplies
• Certain home support services (such as, when
necessary, visits by trained dialysis workers to
check on yout• home dialysis, to help in
emergencies, and check your dialysis equipment and
water supply)
Certain drugs for dialysis are covered under your Medicare
Part B drug benefit. For information about coverage for• Part
B Drugs, please go to the section below, "Medicare Part B
prescription drugs."
*Prior authorization rules apply for certain services; contact
Member Services for information,
$0 for kidney disease
education services received
from your PCP
$0 for kidney disease
education setvices received
fi•om other providers
$0 for in- and out-of area
outpatient dialysis
Inpatient dialysis — refer to
inpatient hospital care at the
beginning of this benefits
chart
$0 for home dialysis
equipment and supplies
$0 per visit for Medicare-
covered home support
services
GRP 12 224/225 D H4524 23 ME PPO_ESA SCH COPAY (Y2013)
Aetna Medicaresn'` Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services '
Generally, you will get your SNF care from network
facilities. However, under certain conditions listed below,
you may be able to pay in-network cost shai�ing for a
facility that isn't a network provider, if the facility accepts
our plan's amounts for payment.
• A nursing home or continuing care retirement
community where you were living right before you
went to the hospital (as long as it provides skilled
nursing facility care).
• A SNF where your spouse is living at the time you
leave the hospital.
*Prior authorization rules
�
Smoking and tobacco use cessation (counseling to
stop smoking or tobacco use)
If you use tobacco but do not ha�e si�ns or svmntoms of
tobacco-related disease: We cover two counseling qult
attempts within a 12-month period as a preventive service
with no cost to you. Each counseling attempt includes up to
four face-to-face visits.
If vou use tobacco and have been dia�nosed with a tobacco-
related disease or are takin� medicine that mav be affected
bv tobacco: We cover cessation counseling seivices. We
cover two counseling quit attempts within a 12-month
period. Each counseling attempt includes up to four face-to-
face visits.
Urgently neecled care
Urgently needed care is care provided to treat a non-
emergency, unforeseen medical illness, injury, or condition
that requires immediate inedical care. Urgently needed cai•e
may be furnished by in-network providei•s or by out-of-
networlc providers when network providers are temporarily
unavailable or inaccessible.
If you haven't been diagnosed
with an illness caused or
complicated by tobacco use:
$0 copay
If you have been diagnosed
with an illness caused or
complicated by tobacco use, or
you take a medicine that is
affected by tobacco: $0 copay
$0 copay for each Medicare-
covered urgently needed care
VISIt
GRP 12 224/225 D H4524 25 ME PPO ESA SCH COPAY (Y2013)
Aetna MedicareS"f Plan (PPO)
2013 Medical Benefits Chart (Schedule of Copayments/Coinsurance)
What you must pay (after
Services that are covered for you deductible) when you get
these services
:�
��Welcome to Medicare" Preventive Visit
The plan covers the one-time "Welcome to Medicare"
preventive visit. The visit includes a review of your health,
as well as education and counseling about the preventive
services you need (including certain screenings and shots),
and referrals for other care if needed.
Important: We cover the "Welcome to Medicare" preventive
visit only within the first 12 months you have Medicare Part
B. When you tnake your appointment, let your doctor's
office know you would like to schedule your "Welcome to
Medicare" preventive visit.
Thet•e is no coinsurance,
copayment, or deductible for the
"Welcome to Medicare"
preventive visit
*Note: See Chapter 4, Section 2.1 of the Evidence of Coverage for information on prior
authorization rules.
GRP 12 224/225 D H4524 27 ME PPO_ESA SCH COPAY (Y2013)
Aetna Medicare Plan (PPO)
2013 Prescription Dr•ug Benefits Chart (Schedule of Copayments/Coinsurance)
Initial Coverage Stage: Amount you pay, up to $2,970 in total cover•ed prescription drug
eYpenses:
�� 3 Tier Plan Networlc retail Network retail Preferred Out-of- �
E phai•macy or non- mail order network ��
�. (up to a 31-day preferred mail pharmacy pharmacy* ��
; supply) order pharmacy (up to a 90-day (up to a 31-day ��
�� (up to a 90-day supply) supply) ��,
�� Su��IY) .. _,.. � �,_ . � �, k�
fl� .F:� �. .. . . .. _. „_ �, �_ .. ; M �-� � �
� Tier ,1 �,. _. �$10 $30 $2 �l �
� Generic Drugs
�
� ,:�... _� .___ __ _-�� _���� ,� �,. _ � � ..-� . ��
u,.� _ . .�__ u ,�. �. �..� r_.�_ ��,.�.
��Tier 2 � _, ,.w _ ..._ $20 $60 $40 $20 `.�
GPreferred Brand f'
� Drugs �
� `
..�. � . ,., � �M k.� � .��, �_�,:.,��
��. � �.��, _ �_. v,... . � .�__. ._��.
� Tier �3 .� , ,� ..v�.. _ _��_ ,� .. . -�. $60 � u _ � $180 $120 $60 �
; Non-Preferred �
��� Brand Drugs �
r �
�3..r _� , ���, �� _.�� . ��,�_,� ,�, � ,
--�� ._. ,...�_ . _ « ,�_�_
v.-� _ a�_,.w � �._r _. _��, _ �.ri_
;� . _ .. _.
*Coverage is limited to certain situations; see the Evidence of Coverage chapter titled "Using the
plan's coverage for your Part D prescription drugs," Section 2.5.
Coverage Gap Stage: Amount you pay after you reach $2,970 in total covered prescription drug
expenses, and until you reach $4,750 in out-of-pocket covered prescription drug costs.
�� 3 Tier Plan Network retail Network retail Preferred Out-of- �R
� pharmacy or non- mail order network �
�
�, (up to a 31-day preferred mail pharmacy pharmacy" A
�� supply) order pharmacy (up to a 90-clay (up to a 31-day ��
F
(up to a 90-day supply) supply) ��
C� . supl?lY) `�
r .._ .. ; , � . _ ,, ,_ , � =�w ., � .
� Tier 1 �. ,$10 � � $30 $20 $10 �
�
� Genet•ic Drugs "
� �
�_�..r . �,. .., .;.., ,.;.. .; . ,._ . ,. . .. , �; ,. ._. ... . ,. �_�, .,,.-;, . .., .. .s, .,43
.,, �. ,� _ . . .... . . .. ... . _,_ ,- . ...
�.Tier 2 $20 $60 $40 $20 �
� Preferred ��
��
�; Brand Drugs ��
�
,
�.� � . . .,. ., . w, . . _ ,.. -. �
GRP 12 227 F 2 H4524 ME RX SCH COPAY (Y2013)
Aetna Medicare Plan (PPO)
2013 Prescription Drug Benefits Chart (Schedule of Copayments/Coinsurance)
request. Review the Aetna Medicare 2013 Gr•oup FormzalaYy (List of Covef•ed Drugs) foi• more
information.
GRP 12 227 F 4 H4524 ME RX SCH COPAY (Y2013)
City of Fort Worth, Texas
Mayor and Council Comr�unication
COUNCIL ACTION: Approved on 9/11/2012
DATE: Tuesday, September 11, 2012 REFERENCE NO.: C-25822
LOG NAME: 14MEDICARE
Si TR.TECT:
Authorize Execution of an Agreement with Aetna Life Insurance Company for Administration of Fully
Insured Medicare Advantage Plans in the Amount Up to $1,188,192.00 for the First Year (ALL COUNCIL
DISTRICTS)
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FiJND CENTERS:
TO Tund/Account/Centers
FROM Fund/Account/Centers
FE85 534730 0148540 �891.144.00
C'ERTIFICATIONS:
Submitted for Citv Manager's Office bv: Susan Alanis (8180)
Or�inating D�artment Head: Karen Marshall (7783)
Additional Information Contact: Margaret Wise (8058)
ATTACHMENTS
FTC(' AT. TNFnRMATION:
1. 14Medicare MWBE.pdf
2. fundin,g. verification.�df