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63.43.300.1 B (1/14 )
63.44.312.1 C (1/15)
Table of contents
Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company or
Aetna Health Inc. (together, Aetna). In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans. IN CT, THIS PLAN IS ISSUED ON AN INDIVIDUAL BASIS AND IS REGULATED
AS AN INDIVIDUAL HEALTH INSURANCE PLAN.
Aetna does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or
health status in the administration of the plan, including enrollment and benefit determinations.
160
years
Your confidence
Aetna has been in business for more than 160
years. We strive to direct our business and our
industry toward more simple and honest services.
Your doctors
Our goal is to provide you with quality health
care at an affordable price. And we have tools
to help you find your doctor (or a new doctor in
your area) who will help you get the most out
of your benefits.
Your prescriptions
All of our plans combine prescription drug
coverage and medical care.
Your way
63.44.324.1 A (1/15)
Coinsurance
Out-of-pocket maximum
Copayment
Premiums
Online
Go to http://www.aetnaindividual.com for easy ways to find the plan
that is best for you.
By mail
Complete and return the enclosed enrollment form.
By phone
Call us toll-free at 1-800-MY-HEALTH (1-800-694-3258, TTY: 711).
Were available from 8 a.m. to 9:30 p.m. ET, Monday through Friday.
We can also help you complete the application.
Material name
Description
Welcome
Doctor visit
Plan documents
(Certificate of
Coverage, etc.)
Delivery
Questions?
Call us tollfree at
1-800-MY-HEALTH
(1-800-694-3258,
TTY: 711).
Were available from
8 a.m. to 9:30 p.m. ET,
Monday through Friday.
Or visit us at
http://www.aetna.com.
Walk-in clinics
These health care clinics are located in retail stores,
supermarkets and pharmacies. They treat uncomplicated,
minor illnesses. They also provide preventive health care
services. Walk-in clinics (or convenient care clinics) are
often open nights, weekends and holidays when you
cant see your regular provider.
E-visits
These are electronic visits between you and your health
care providers. You can send a medical concern to them,
and they can securely give you medical advice and/or
care. They can also prescribe medication/therapy online.
Embedded deductible
An embedded deductible, also known as aggregate,
means one person on a plan with 2+ members can
meet the individual deductible and begin receiving
covered benefits.
Scenario:
Suppose you have a plan with four family members,
John, Jane, Billy and Katie. Each family member has a
$500 individual deductible OR $1,000 for the family.
John meets his $500 individual deductible; therefore, he
can start receiving covered plan benefits. The remaining
3 family members can contribute any portion to satisfy
the $1,000 family deductible. Jane can contribute
$125, Billy $275 and Katie can contribute the final
$100. Or Jane can contribute the entire $500. Then
the family deductible is met.
Note: This is an example for illustrative purposes only. The
amounts above do not reflect an actual plan deductible.
Family coverage
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*Referrals are required for HMO plans and all plans in New York and New Jersey.
Visit http://www.aetna.com/health-reform-connection/index.html
Accountable care
health care focused on you
Your care. Your choice.
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Have questions?
Just call us
To find out more about
accountable care networks
and how you can improve
your health while lowering
your health care costs,
visit http://www.aetna
individual.com
or call
1-800-MY-HEALTH
(1-800-694-3258,
TTY: 711).
*Estimated costs not available in all markets. Actual costs may differ for a number of reasons, including if other or different
services are performed by the doctor or facility at the time of your visit, and/or additional claims/member payments are
processed before the actual claim for the estimated service is processed.
Save money
use Aetnas provider network
Maybe youve read that one of the best ways to save on health care costs is
to stay in network. But youre not sure what that means.
Youre not alone. Many people find the term confusing. Were here to help
you understand what in network means for you.
Visit http://www.aetna
individual.com
and select Find a Doctor,
or call 1-800-MY-HEALTH
(1-800-694-3258,
TTY: 711), and ask for
provider information.
This contract rate is usually much lower than what the doctor would
charge if you were not an Aetna member. And the network doctor agrees
to accept the contract rate as payment. You pay your coinsurance or copay,
along with your deductible, if applicable.
So what does this all mean? It means you have access to the care you need
at a lower price. And the difference in cost can be huge for the same
type of service or procedure.
Example 1
You have been getting care for an ongoing condition from a specialist who is not in the Aetna network. You are thinking about
switching to a specialist in the Aetna network. This example illustrates what you may save if you switch.
Office visit
In Network
Out of Network
Amount billed
$150
$150
$90*
$90
$90
80%
60%
$72*
$54**
$18
$36
$0
$60
$18***
$96***
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Doctor bill
$90**
Example 2
You need outpatient surgery for a simple procedure and are deciding if you will have it done by a physician in the Aetna network.
This example gives you an idea of how much you might owe depending on your choice.
Outpatient surgery
In network
Out of network
$2,000
Surgery bill
Amount billed
$2,000
$600*
$600**
$600
$600
80%
60%
$480*
$360**
$120
$240
$0
$1,400
$120***
$1,640***
Example 3
You need to go to the hospital, but it is not an emergency. It turns out that you have to stay in the hospital for five days.
This example gives you an idea of how much you might owe to the hospital depending on whether it is in the Aetna network.
In network
Out of network
Hospital bill
Amount billed
$25,000
$25,000
$8,750*
$8,750**
$8,750
$8,750
80%
60%
$7,000*
$5,250**
$1,750
$3,500
$0
$16,250
$1,750***
$19,750***
* Doctors, hospitals and other health care providers in the Aetna network accept our payment rate and agree that you owe only your
copay, coinsurance and deductible.
** When you go out of network, the plan determines a recognized amount. You may be responsible for the difference between the
billed amount and the recognized amount. See your plan documents for details. Your plan may instead call the recognized amount
the recognized charge.
*** Most plans cap out-of-pocket costs for covered services. The deductible and coinsurance you owe count toward that cap. But when
you go outside the network, the difference between the health care providers bill and the recognized amount does not count
toward that cap.
You also may be responsible for a portion of fees charged by the facility in which the surgery takes place. The figures in the example
do not include those facility fees.
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With most plans, your coinsurance is higher for out-ofnetwork care. Coinsurance is the part of the covered service
you pay for. (For example, the plan pays 80 percent of the
covered amount, and you pay 20 percent coinsurance.)
What you pay when you are balance billed does not
count toward your deductible. And it is not part of any
cap your plan has on how much you have to pay for
covered services.
Many plans have a separate out-of-network deductible.
This is usually higher than your in-network deductible.
(Sometimes, you have no deductible at all for care
in the network.) You must meet the out-of-network
deductible before your plan pays any out-of-network
benefits.
Featuring:
VA Aetna Catastrophic 100% PD
63.06.300.1-VA G (1/15)
Unlike metal-level coverage, this plan is a catastrophic plan offering. Only individuals
who are younger than age 30 or have a hardship exemption may enroll in this plan.
Member benefits
In network
Out of network*
$6,600/$13,200
$13,500/$27,000
Member coinsurance
0%
50%
$6,600/$13,200
Unlimited/unlimited
Specialist visit
Hospital stay
Emergency room
Urgent care
Diagnostic lab
Diagnostic X-ray
Pharmacy deductible
Nonpreferred drugs
Specialty drugs**
Not covered
Vision
Pediatric eye exam (1 visit per year)2
Pediatric dental
Pharmacy
*For important information on your costs and how Aetna pays for out-of-network care, read Costs for out-of-network doctors
and hospitals.
**P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.
1The family deductible and/or out-of-pocket limit can be met by a combination of family members. Each covered family member
only needs to satisfy his or her individual deductible and/or out-of-pocket limit. Deductible and/or out-of-pocket limit are separate
in and out of network.
2Any applicable benefit maximums are combined in and out of network.
Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company or
Aetna Health Inc. (together, Aetna). In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans.
63.06.300.1-VA G (1/15)
1. Go to http://www.aetnaindividual
docfind.com.
2. Enter your ZIP code or city and state.
3. Type a name, specialty, procedure
or condition in the What are you
looking for? box or search from
a list of conditions, procedures or
provider types.
4. Select a plan with either Aetna
Coastal or Aetna Whole Health in
the plan name, depending on where
you live, from the drop-down menu
5. If you search by provider name, make
sure to click on see accepted plans
to see if the Community plan you want
is listed.
This material is for information only. A summary of exclusions is listed in the Aetna Health Plan brochure. For a full list of benefits
coverage and exclusions, refer to the plan documents. Rates and benefits vary by location. Aetna receives rebates from drug
manufacturers that may be taken into account in determining Aetnas Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Health insurance plans contain exclusions and limitations. Information is
believed to be accurate as of the production date; however, it is subject to change.
Featuring:
63.06.300.1-VA G (1/15)
Member benefits
In network
Out of network*
$6,300/$12,600
$12,600/$25,200
Member coinsurance
0%
50%
$6,300/$12,600
Unlimited/unlimited
Specialist visit
Hospital stay
Urgent care
Diagnostic lab
Diagnostic X-ray
Pharmacy deductible
Nonpreferred drugs
Specialty drugs**
Not covered
Vision
Pediatric eye exam (1 visit per year)2
Pediatric dental
Pharmacy
*For important information on your costs and how Aetna pays for out-of-network care, read Costs for out-of-network doctors
and hospitals.
**P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.
1The family deductible and/or out-of-pocket limit can be met by a combination of family members. Each covered family member
only needs to satisfy his or her individual deductible and/or out-of-pocket limit. Deductible and/or out-of-pocket limit are separate
in and out of network.
2Any applicable benefit maximums are combined in and out of network.
Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company or
Aetna Health Inc. (together, Aetna). In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans.
63.06.300.1-VA G (1/15)
Out of network*
$5,750/$11,500
$11,500/$23,000
0%
50%
$6,600/$13,200
Unlimited/unlimited
Not covered
This material is for information only. A summary of exclusions is listed in the Aetna Health Plan brochure. For a full list of benefits
coverage and exclusions, refer to the plan documents. Rates and benefits vary by location. Aetna receives rebates from drug
manufacturers that may be taken into account in determining Aetnas Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Health insurance plans contain exclusions and limitations. Investment
services are independently offered by the HSA Administrator. Information is believed to be accurate as of the production date;
however, it is subject to change.
Featuring:
63.06.300.1-VA G (1/15)
Member benefits
In network
Out of network*
$2,750/$5,500
$7,500/$15,000
Member coinsurance
30%
50%
$6,250/$12,500
Unlimited/unlimited
Specialist visit
Hospital stay
Urgent care
Diagnostic lab
Diagnostic X-ray
Pharmacy deductible
Nonpreferred drugs
Specialty drugs***
Not covered
Vision
Pediatric eye exam (1 visit per year)2
Pediatric dental
Pharmacy
*For important information on your costs and how Aetna pays for out-of-network care, read Costs for out-of-network doctors
and hospitals.
**T1A=Value drugs; T1=Preferred generic drugs.
***P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.
1The family deductible and/or out-of-pocket limit can be met by a combination of family members. Each covered family member
only needs to satisfy his or her individual deductible and/or out-of-pocket limit. Deductible and/or out-of-pocket limit are
separate in and out of network.
2Any applicable benefit maximums are combined in and out of network.
Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company or
Aetna Health Inc. (together, Aetna). In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans.
63.06.300.1-VA G (1/15)
Out of network*
$4,000/$8,000
$7,500/$15,000
30%
50%
$6,600/$13,200
Unlimited/unlimited
$500/$1,000
$1,000/$2,000
Not covered
This material is for information only. A summary of exclusions is listed in the Aetna Health Plan brochure. For a full list of benefits
coverage and exclusions, refer to the plan documents. Rates and benefits vary by location. Aetna receives rebates from drug
manufacturers that may be taken into account in determining Aetnas Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Health insurance plans contain exclusions and limitations. Information is
believed to be accurate as of the production date; however, it is subject to change.
Featuring:
63.06.300.1-VA G (1/15)
Member benefits
In network
Out of network*
$1,400/$2,800
$6,750/$13,500
Member coinsurance
20%
50%
$5,650/$11,300
Unlimited/unlimited
Specialist visit
Hospital stay
Urgent care
Diagnostic lab
Diagnostic X-ray
Pharmacy deductible
IN: $250/$500
IN: $500/$1,000
Nonpreferred drugs
Specialty drugs***
Not covered
Vision
Pediatric eye exam (1 visit per year)2
Pediatric dental
Pharmacy
*For important information on your costs and how Aetna pays for out-of-network care, read Costs for out-of-network doctors
and hospitals.
**T1A=Value drugs; T1=Preferred generic drugs.
***P=Preferred specialty drugs; NP=Nonpreferred specialty drugs.
1The family deductible and/or out-of-pocket limit can be met by a combination of family members. Each covered family member
only needs to satisfy his or her individual deductible and/or out-of-pocket limit. Deductible and/or out-of-pocket limit are
separate in and out of network.
2Any applicable benefit maximums are combined in and out of network.
Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company or
Aetna Health Inc. (together, Aetna). In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans.
63.06.300.1-VA G (1/15)
1. Go to http://www.aetnaindividual
docfind.com.
2. Enter your ZIP code or city and state.
3. Type a name, specialty, procedure
or condition in the What are you
looking for? box or search from
a list of conditions, procedures or
provider types.
4. Select a plan with either Aetna
Coastal or Aetna Whole Health in
the plan name, depending on where
you live, from the drop-down menu
5. If you search by provider name, make
sure to click on see accepted plans
to see if the Community plan you want
is listed.
This material is for information only. A summary of exclusions is listed in the Aetna Health Plan brochure. For a full list of benefits
coverage and exclusions, refer to the plan documents. Rates and benefits vary by location. Aetna receives rebates from drug
manufacturers that may be taken into account in determining Aetnas Preferred Drug List. Rebates do not reduce the amount a
member pays the pharmacy for covered prescriptions. Health insurance plans contain exclusions and limitations. Information is
believed to be accurate as of the production date; however, it is subject to change.
Rating areas*
Virginia
Due to changes related to health care reform, the federal government redefined rating areas. This list of rating
areas shows where Aetna Health Plans are available in your state. Just look for your county in one of the area
listings below.
Your rates will depend on the area in which your county is located. For more information or a quote on what
your rate would be, call your broker or 1-800-MY-HEALTH (1-800-694-3258).
Area 6
Area 7
Giles
Montgomery
Pulaski
Radford
Bedford
Bedford City
Amelia
Charles City
Chesterfield
Colonial Heights City
Cumberland
Dinwiddie
Goochland
Hanover
Area 8
Area 9
Area 12
Botetourt
Craig
Franklin
Roanoke
Roanoke City
Salem
Gloucester
Hampton City
Isle of Wight
James City
Mathews
Newport News City
Williamsburg City
York
Bland
Carroll
Essex
Floyd
Galax City
Lancaster
Lexington City
Middlesex
63.02.300.1-VA D (1/15)
Area 1
* Networks may not be available in all zip codes and are subject to change.
Henrico
Hopewell City
King and Queen
New Kent
Petersburg City
Powhatan
Prince George
Richmond City
Northumberland
Nottoway
Tazewell
Wythe
1-800-MY-HEALTH (1-800-694-3258).
Para obtener asistencia en Espaol, llame al
1-800-MY-HEALTH (1-800-694-3258).
To get help in
another language,
call 1-800-MY-HEALTH
(1-800-694-3258).
63.44.316.1 C (1/15)
Your coverage
Your coverage stays in effect as long as you pay the
required monthly payment on time, and as long as you
are eligible in the plan. Your coverage ends if you:
Dont pay your monthly bill
Move to a state or location where Aetna Health
Plans arent available
Get duplicate coverage
Reversal of sterilization
Services for the treatment of sexual dysfunction or
inadequacies including therapy, supplies or counseling
Special or private duty nursing
Weight control services including surgical procedures,
medical treatments, weight control/loss programs,
dietary regimens, and supplements, appetite
suppressants and other medications; food or food
supplements, exercise programs, exercise or other
equipment; and other services and supplies that are
primarily intended to control weight or treat obesity,
including morbid obesity, or for the purpose of
weight reduction, regardless of the existence of
comorbid conditions
Pediatric dental
These medical plans dont cover all pediatric dental
care expenses and include limitations and exclusions.
Please refer to your plan documents to see which services
we cover. The following is a partial list of services and
supplies that we generally dont cover. However, your
plan documents may have exceptions to this list.
We base these documents on state laws, essential
health benefits, or the plan design or rider(s) you buy.
All pediatric dental services not specifically covered
in, or that your plan documents limit or exclude,
including costs of services before coverage begins
and after coverage ends
Instructions for diet, plaque control and oral hygiene
Dental services or supplies that you may primarily
use to change, improve or enhance appearance
Dental implants
Experimental or investigational drugs, devices,
treatments or procedures
Services not necessary for the diagnosis, care or
treatment of a condition
Orthodontic treatment that isnt medically necessary
for a severe or handicapping condition
Replacement of lost or stolen appliances
Services and supplies provided where there is no
evidence of pathology, dysfunction or disease
Getting help
Contact us
Member Services can help with your questions. To contact
Member Services, call the toll-free number on your ID card.
Or, call 1-800-US-Aetna (1-800-872-3862) Monday through
Friday, 7 a.m. to 7 p.m. ET. You can also send Member Services
an e-mail. Just go to your secure Aetna Navigator member
website at www.aetna.com. Click on Contact Us after you
log in.
63.28.300.1 E (1/15)
Your plan documents list all the details for the plan you
choose. This includes whats covered, whats not covered
and what you will pay for services. Plan document names
vary. They may include a Schedule of Benefits and Certificate
of Coverage.
*Aetna Health Plans for Individuals, Families and the Self-Employed are underwritten by Aetna Life Insurance Company and/
or Aetna Health Inc. (together, Aetna). In some states, individuals may qualify as a business group of one and may be
eligible for guaranteed issue, small group health plans.
You will share in the cost of your health care. These are called
out-of-pocket costs. Your plan documents show the amounts
that apply to your specific plan. Those costs may include:
Copay a set amount (for example, $15) you pay for covered
health care service. You usually pay this when you get the
service. The amount can vary by the type of service. For
example, you may pay a different amount to see a specialist
than you would pay to see your family doctor.
Coinsurance your share of the costs for a covered service.
This is usually a percent (for example, 20%) of the allowed
amount for the service. For example, if the health plans
allowed amount for an office visit is $100 and youve met
your deductible, your coinsurance payment of 20% would be
$20. The health plan pays the rest of the allowed amount.
Deductible the amount you owe for health care services
before your health plan begins to pay. For example, if your
deductible is $1,000, you have to pay the first $1,000 for
covered services before the plan begins to pay. You may
not have to pay for some services. Other deductibles may
apply at the same time:
- Inpatient Hospital Deductible This deductible applies
when you are a patient in a hospital.
- Emergency Room Deductible This is the amount you pay
when you go to the emergency room. If you are admitted to
the hospital within 24 hours, you wont have to pay it.
The Inpatient Hospital and Emergency Room Deductibles are
separate from your general deductible. For example, your plan
may have an overall $1,000 deductible and also has a $250
Emergency Room Deductible. This means that you pay the first
$1,000 before the plan pays anything. Once the plan starts to
pay, if you go to the emergency room you will pay the first $250
of that bill.
Your plan documents list all the services that require you
to get precertification. If you dont, you will have to pay for
all or a larger share of the cost for the service. Even with
precertification, you will usually pay more when you use
out-of-network doctors.
Call the number shown on your Aetna ID card to begin the
process. You must get the precertification before you receive
the care.
You do not have to get precertification for emergency services.
What we look for when reviewing a request
First, we check to see that you are still a member. And we
make sure the service is considered medically necessary
for your condition. We also make sure the service and place
requested to perform the service are cost effective. We may
suggest a different treatment or place of service that is just as
effective but costs less. We also look to see if you qualify for
one of our case management programs. If so, one of our
nurses may contact you.
Precertification does not verify if you have reached any plan
dollar limits or visit maximums for the service requested.
So, even if you get approval, the service may not be covered.
You may have to try one drug before you can try another
Step therapy means you have to try one or more drugs before
a step-therapy drug will be covered. The preferred drug
list includes step-therapy drugs. Your doctor might want you
to skip one of these drugs for medical reasons. If so, you,
someone helping you or your doctor can ask for a medical
exception. Your pharmacist can also ask for an exception for
antibiotics and pain medicines.
We want you to feel good about using the Aetna network for
behavioral health services. Visit www.aetna.com/docfind
and click the Get info on Patient Safety and Quality link.
No Internet? Call Member Services instead. Use the toll-free
number on your Aetna ID card to ask for a printed copy.
See what other medical and government groups say about it.
That includes the federal Agency for Health Care Research
and Quality.
Must be the right type in the right amount for the right
length of time and for the right body part
Ask experts.
Living will spells out the type and extent of care you
want to receive
Vendors
Government authorities
Quality assessment
Audits
Birth
Adoption
Georgia
Illinois
Kansas
North Carolina
Procedures and medically based criteria for determining
whether a specified procedure, test or treatment is
experimental are available upon request.
63.44.318.1 C (1/14)
Ready to enroll?
Visit http://www.aetnaindividual.com to
complete the enrollment form online.
This material is for information only. Plan features and availability may vary by location. Rates and benefits may vary by location. Health
benefits and insurance plans and dental insurance plans contain exclusions and limitations. Investment services are independently offered
by the HSA administrator. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice.
Aetna does not provide care or guarantee access to health services. Not all health/dental services are covered. See plan documents for a
complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives
rebates from drug manufacturers that may be taken into account in determining Aetnas Preferred Drug List. Rebates do not reduce
the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a
subsidiary of Aetna Inc., which is a licensed pharmacy providing prescription services by mail. Health information programs
provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional.
Information is believed to be accurate as of production date; however, it is subject to change.
Policy forms issued in Oklahoma include: Comprehensive PPO-GR-11741 (5/04), Limited-GR-11741-LME (5/04) and Dental-11826 Ed 9/04.
For more information about Aetna plans, refer to www.aetna.com.