This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered . However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased.
Typically,members will pay substantially more money out of their own pocket if they choose to use an out-of-network doctor. The out-ofnetwork provider will be paid based on Aetna's "recognized charge". This is not the same as the billed charge from the doctor. Aetna pays a percentage of the recognized charge, as defined in the member's plan. The member may have to pay the difference between the out-of-network provider's billed charge and Aetna's recognized charge, plus any coinsurance and deductibles due under the plan. Note that any amount the doctor bills the member above Aetna's recognized charge does not count toward the member's deductible or out-of-pocket maximums. The recognized charge for out-of-network doctors and other out-of-network health care providers is a percentage (100 percent or above) of the rate that Medicare pays them. For out-of-network hospitals and other out-of-network facilities, Aetna pays a percentage as defined in the member's plan of the reasonable and customary charge as determined by Aetna. Note that any amount the doctor bills the member above Aetna's recognized charge does not count toward the member's deductible or out-of-pocket maximums.
This benefit applies when members choose to get care out of network. When members have no choice in the doctors they see (for example, an emergency room visit after a car accident), they are generally not responsible for the extra out-of-network costs.
Cosmetic surgery, other than reconstructive surgery following a mastectomy;
What's Not Covered Nonmedically necessary services or supplies;
If you had no prior creditable coverage within 63 days prior to your enrollment date (either because you had no prior coverageor because there was more than a 63 day gap from the date your prior coverage terminated to your enrollment date), we willapply your plan's pre-existing conditions exclusion.This material is for informational purposes only and is not an offer or invitation to contract. An application must be completedto obtain coverage. Plan features and availability may vary by location and group size. Not all heath services are covered. Seeplan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features aresubject to change. With the exception of Aetna Rx Home Delivery, Providers are independent contractors and are not agentsof Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to healthservices.Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead tosubstantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are notlimited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse(detoxification, inpatient and outpatient rehabilitation). When the Member's preferred provider is coordinating care, thepreferred provider will obtain the precertification. Precertification requirements may vary.Pre-existing Conditions Exclusion ProvisionThis plan imposes a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditablecoverage) and may not be applicable to you. A pre-existing condition exclusion means that if you have a medical conditionbefore coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for thatcondition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended orreceived or for which the individual took prescribed drugs within 6 months.Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period forcoverage, the 6 month period ends on the day before the waiting period begins. The exclusion period, if applicable, may lastup to 12 months from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period.In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copyof any Certificates of Creditable Coverage you have. Please contact your Aetna Member Services representative at1-800-80-AETNA if you need assistance in obtaining a Certificate of Creditable Coverage from your prior carrier or if you haveany questions on the information noted above.The pre-existing condition exclusion does not apply to pregnancy nor to a child who is under the age of 19. Note: For lateenrollees, coverage will be delayed until the plan's next open enrollment; the pre-existing exclusion will be applied from theindividual's effective date of coverage.If you had prior creditable coverage within 63 days immediately before the date you enrolled under this plan, then the preexistingconditions exclusion in your plan, if any, will be waived.NY OA MC 3-10/10 v. 6/3/10 Page 7Aetna Life Insurance Company PLAN DESIGN AND BENEFITS - New York Open Access Managed Choice 3-10/10New York Small Group Open Access MCPlan Effective Date: 10/01/2010© 2010 Aetna Inc.For more information about Aetna plans, refer to www.aetna.com.determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for coveredprescriptions. In addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on apercentage basis or a deductible, use of formulary drugs may not necessarily result in lower costs for the member. Membersshould consult with their treating physicians regarding questions about specific medications. Refer to your plan documents orcontact Member Services for information regarding the terms and limitations of coverage.Plans are provided by Aetna Life Insurance Company.Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna, Inc., that is a licensed pharmacyproviding mail-order pharmacy services. Aetna's negotiated charge with Aetna Rx Home Delivery may be higher than AetnaRx Home Delivery's cost of purchasing drugs and providing mail-order pharmacy services.In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.If your plan covers outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is alist of prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicablelimitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. Themedications listed on the formulary are subject to change in accordance with applicable state law. For information regardinghow medications are reviewed and selected for the formulary, formulary information, and information about other pharmacyprograms such as precertification and step-therapy, please refer to Aetna's website at Aetna.com, or the Aetna MedicationFormulary Guide. Aetna receives rebates from drug manufacturers that may be taken into account in