summary of benefits - aetna · summary of benefits aetna golden choice™ plan january 1, 2005 –...

Summary of Benefits

Aetna Golden Choice™ Plan

January 1, 2005 – December 31, 2005 Lehigh, Monroe, Northampton, Schuylkill Counties

7A-40914.1 LMNS (9/04) 18.06.334.1-PA2 PENDING FEDERAL APPROVAL

Introduction to the

Summary of Benefits

for Aetna Golden Choice™ Plan

January 1, 2005 - December 31, 2005

Lehigh, Monroe, Northampton, Schuylkill Counties

Where is Aetna Golden Choice Plan Available? Thank you for your interest in Aetna Golden Choice Plan. Our

plan is offered by Aetna Health Inc., a Medicare Advantage Preferred Provider Organization (PPO). This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Aetna Health, Inc. and ask for the "Evidence of Coverage".

The service area for this plan includes: Lehigh, Monroe, Northampton, Schuylkill Counties, PA. You must live in one of these places to join the plan. Can I Choose My Doctors? Aetna Health, Inc. has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list. Our number is listed at the end of this introduction.

You Have Choices in Your Health Care. As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Aetna Golden Choice Plan. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare program.

What Happens if I Go to a Doctor Who’s Not in Your Network? You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network. For more information, please call the number at the end of this introduction.

How Can I Compare My Options? You can compare Aetna Golden Choice Plan and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare

Plan offers. We also offer additional benefits, which may change from year to year.


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What Should I Do if I Have Other Insurance in Addition to Medicare?

whether to continue for another year. Even if a Medicare health plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for health care coverage in your area and give you information about your right to get Medicare supplemental insurance coverage. You can choose another health plan if one is available, or you can receive care from the Original Medicare Plan.

If you have Medicare supplemental insurance that fills gaps in the Original Medicare Plan, you may not need it if you join Aetna Golden Choice Plan. If you drop your supplemental policy, you may not be able to get the same one back. You should check into this carefully before you drop your supplemental policy to make sure you have all of the coverage you need.

You or your spouse may have, or be able to get, employer group health coverage. If so, you should talk to the employer to find out how your benefits will be affected if you join Aetna Golden Choice Plan. Get this information before you decide.

If Aetna Health, Inc. ever denies your claim or a service, we will explain our decision to you. You always have the right to appeal and ask us to review the claim or service that was denied. If a decision is not made in your favor, your appeal will be reviewed by an independent organization that works for Medicare.

What Are My Protections in This Plan? All health plans in the Medicare program agree to stay with the program for a full year at a time. Each year, the plans decide

Please call Aetna Health Inc. for more information about this plan. Customer Service Hours:

Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 5:00 p.m. Eastern Current members should call 1-800-282-5366. (TTY/TDD 1-800-628-3323)

Prospective members should call 1-800-832-2640. (TTY/TDD 1-800-628-3323)

Please call Medicare at 1-800-MEDICARE (1-800-633-4227) (24 hours a day/7 days a week) or visit www.medicare.gov for more information about Medicare.

(TTY/TDD 1-877-486-2048)

If you have special needs, this document may be available in other formats.


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http://www.medicare.gov/

If you have any questions about this plan's benefits or costs, please contact Aetna Health Inc. at 1-800-282-5366 (for current members) and 1-800-832-2640 (for prospective members).

Benefit Category

Original Medicare

Aetna Golden Choice Plan Option 1 Lehigh, Monroe, Northampton,

Schuylkill Counties

Aetna Golden Choice Plan Option 2


IMPORTANT INFORMATION 1 - Premium and Other Important Information

You pay the Medicare Part B premium of $78.20 each month.

You pay $25 each month. You also continue to pay the Medicare Part B premium of $78.20 each month You pay one initial deductible of $150 for the following plan services when received out of network only: - Inpatient Hospital Care - Inpatient Mental Health Care - Doctor Office Visits - Chiropractic Services - Podiatry Services - Outpatient Mental Health Care - Outpatient Substance Abuse Care - Outpatient Services/Surgery - Ambulance Services - Outpatient Rehabilitation Services - Durable Medical Equipment - Prosthetic Devices - Diabetes Self-Monitoring Training and Supplies - Diagnostic Tests, X-Rays, and Lab Services - Bone Mass Measurement - Colorectal Screening Exam - Immunizations - Mammograms (Annual Screenings) - Pap Smears and Pelvic Exams - Prostate Cancer Screening Exams

You pay $65 each month. You also continue to pay the Medicare Part B premium of $78.20 each month. You pay one initial deductible of $150 for the following plan services when received out of network only: - Inpatient Hospital Care - Inpatient Mental Health Care - Doctor Office Visits - Chiropractic Services - Podiatry Services - Outpatient Mental Health Care - Outpatient Substance Abuse Care - Outpatient Services/Surgery - Ambulance Services - Outpatient Rehabilitation Services - Durable Medical Equipment - Prosthetic Devices - Diabetes Self-Monitoring Training and Supplies - Diagnostic Tests, X-Rays, and Lab Services - Bone Mass Measurement - Colorectal Screening Exam - Immunizations - Mammograms (Annual Screenings) - Pap Smears and Pelvic Exams - Prostate Cancer Screening Exams


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Benefit Category

Original Medicare





1 - Premium and Other Important Information – continued

- Hearing Services - Vision Services - Routine Physical Exams - CORF - Partial Hospitalization - Other Health Care Professional Services - Clinical/Diagnostic Lab Services - Radiation Therapy Services - Cardiac Rehabilitation Services - Renal Dialysis - Outpatient Blood There is a $5000 maximum out-of-pocket limit every year for the following plan services when received out of network only: - Inpatient Hospital Care - Inpatient Mental Health Care - Doctor Office Visits - Chiropractic Services - Podiatry Services - Outpatient Mental Health Care - Outpatient Substance Abuse Care - Outpatient Services/Surgery - Ambulance Services - Outpatient Rehabilitation Services - Durable Medical Equipment - Prosthetic Devices - Diabetes Self-Monitoring Training and Supplies - Diagnostic Tests, X-Rays, and Lab Services - Bone Mass Measurement

- Hearing Services - Vision Services - Routine Physical Exams - CORF - Partial Hospitalization - Other Health Care Professional Services - Clinical/Diagnostic Lab Services - Radiation Therapy Services - Cardiac Rehabilitation Services - Renal Dialysis - Outpatient Blood There is a $3500 maximum out-of-pocket limit every year for the following plan services when received out of network only: - Inpatient Hospital Care - Inpatient Mental Health Care - Doctor Office Visits - Chiropractic Services - Podiatry Services - Outpatient Mental Health Care - Outpatient Substance Abuse Care - Outpatient Services/Surgery - Ambulance Services - Outpatient Rehabilitation Services - Durable Medical Equipment - Prosthetic Devices - Diabetes Self-Monitoring Training and Supplies - Diagnostic Tests, X-Rays, and Lab Services - Bone Mass Measurement


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Benefit Category

Original Medicare





1 - Premium and Other Important Information - continued

- Colorectal Screening Exam - Immunizations - Mammograms (Annual Screenings) - Pap Smears and Pelvic Exams - Prostate Cancer Screening Exams - Hearing Services - Vision Services - Routine Physical Exams - CORF - Partial Hospitalization - Other Health Care Professional Services - Clinical/Diagnostic Lab Services - Radiation Therapy Services - Cardiac Rehabilitation Services - Renal Dialysis - Outpatient Blood If there is no note that a service is covered out of network, it is generally covered in-network only.

- Colorectal Screening Exam - Immunizations - Mammograms (Annual Screenings) - Pap Smears and Pelvic Exams - Prostate Cancer Screening Exams - Hearing Services - Vision Services - Routine Physical Exams - CORF - Partial Hospitalization - Other Health Care Professional Services - Clinical/Diagnostic Lab Services - Radiation Therapy Services - Cardiac Rehabilitation Services - Renal Dialysis - Outpatient Blood If there is no note that a service is covered out of network, it is generally covered in-network only.

2 - Doctor and Hospital Choice (For more information, see Emergency - #15 and Urgently Needed Care - #16.)

You may go to any doctor, specialist or hospital that accepts Medicare.

You can go to doctors, specialists, and hospitals in or out of the network. Higher costs apply for out of network services. You are covered for the following out of network services: - Inpatient Hospital Care - Inpatient Mental Health Care - Doctor Office Visits - Chiropractic Services - Podiatry Services

You can go to doctors, specialists, and hospitals in or out of the network. Higher costs apply for out of network services. You are covered for the following out of network services: - Inpatient Hospital Care - Inpatient Mental Health Care - Doctor Office Visits - Chiropractic Services - Podiatry Services


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Benefit Category

Original Medicare





2 - Doctor and Hospital Choice - continued

- Outpatient Mental Health Care - Outpatient Substance Abuse Care - Outpatient Services/Surgery - Ambulance Services - Outpatient Rehabilitation Services - Durable Medical Equipment - Prosthetic Devices - Diabetes Self-Monitoring Training and Supplies - Diagnostic Tests, X-Rays, and Lab Services - Bone Mass Measurement - Colorectal Screening Exam - Immunizations - Mammograms (Annual Screenings) - Pap Smears and Pelvic Exams - Prostate Cancer Screening Exams - Hearing Services - Vision Services - Routine Physical Exams - CORF - Partial Hospitalization - Other Health Care Professional Services - Clinical/Diagnostic Lab Services - Radiation Therapy Services - Cardiac Rehabilitation Services - Renal Dialysis - Outpatient Blood

- Outpatient Mental Health Care - Outpatient Substance Abuse Care - Outpatient Services/Surgery - Ambulance Services - Outpatient Rehabilitation Services - Durable Medical Equipment - Prosthetic Devices - Diabetes Self-Monitoring Training and Supplies - Diagnostic Tests, X-Rays, and Lab Services - Bone Mass Measurement - Colorectal Screening Exam - Immunizations - Mammograms (Annual Screenings) - Pap Smears and Pelvic Exams - Prostate Cancer Screening Exams - Hearing Services - Vision Services - Routine Physical Exams - CORF - Partial Hospitalization - Other Health Care Professional Services - Clinical/Diagnostic Lab Services - Radiation Therapy Services - Cardiac Rehabilitation Services - Renal Dialysis - Outpatient Blood


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Benefit Category

Original Medicare





2 - Doctor and Hospital Choice - continued

Authorization rules may apply for out of network services. Contact plan for details. You may pay a penalty for receiving out of network services without authorization from the plan for the following services. Contact plan for details. - Inpatient Hospital Care - Inpatient Mental Health Care - Ambulance Services - Durable Medical Equipment - Prosthetic Devices - Partial Hospitalization

Authorization rules may apply for out of network services. Contact plan for details. You may pay a penalty for receiving out of network services without authorization from the plan for the following services. Contact plan for details. - Inpatient Hospital Care - Inpatient Mental Health Care - Ambulance Services - Durable Medical Equipment - Prosthetic Devices - Partial Hospitalization

SUMMARY OF BENEFITS Inpatient Care 3 - Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services)

You pay for each benefit period: (3) Days 1-60: an initial deductible of $912 Days 61-90: $228 each day Day 91-150: $456 each lifetime reserve day (4)

You pay $750 for each Medicare-covered stay at a network hospital. You pay 30% of the cost for each stay at an out of network hospital.

You pay $250 for each Medicare-covered stay at a network hospital. You pay 20% of the cost for each stay at an out of network hospital.

(3) A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. (4) Lifetime reserve days can only be used once.


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Benefit Category

Original Medicare





3 - Inpatient Hospital Care - continued

Please call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. (4)

Inpatient substance abuse and rehabilitation services are not covered out of network. There is no copayment for additional days received at a network hospital. You are covered for unlimited days each benefit period.

Inpatient substance abuse and rehabilitation services are not covered out of network. There is no copayment for additional days received at a network hospital. You are covered for unlimited days each benefit period.

4 – Inpatient Mental Health Care

You pay the same deductible and copayments as inpatient hospital care (above) except Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime.

You pay $750 for each Medicare-covered stay at a network hospital.

You pay 30% of the cost for each stay at an out of network hospital. Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime.

You pay $250 for each Medicare-covered stay at a network hospital. You pay 20% of the cost for each stay at an out of network hospital. Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime.

5 - Skilled Nursing Facility (in a Medicare-certified skilled nursing facility)

You pay for each benefit period (3), following at least a 3-day covered hospital stay: Days 1-20: $0 for each day Days 21-100: $114 for each day There is a limit of 100 days for each benefit period. (3)(4)

You pay: • $25 each day for day(s) 1-100 for a stay in a Skilled Nursing Facility.

No prior hospital stay is required. You are covered for 100 days each benefit period.

You pay: • $25 each day for day(s) 1-100 for a stay in a Skilled Nursing Facility.

No prior hospital stay is required. You are covered for 100 days each benefit period.

(3) A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. (4) Lifetime reserve days can only be used once.


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Benefit Category

Original Medicare





6 – Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)

There is no copayment for all covered home health visits.

You pay $20 for Medicare-covered home health visits.

You pay $20 for Medicare-covered home health visits.

7 - Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must receive care from a Medicare-certified hospice.

You must receive care from a Medicare-certified hospice.

You must receive care from a Medicare-certified hospice.

Outpatient Care 8 - Doctor Office Visits

You pay 20% of Medicare-approved amounts. (1)(2)

If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details.

You pay $20 to $25 for each primary care doctor office visit for Medicare-covered services. You pay 30% for each out of network primary care doctor office visit. You pay $35 for each specialist visit for Medicare-covered services. You pay 30% for each out of network specialist visit.

You pay $10 to $15 for each primary care doctor office visit for Medicare-covered services. You pay 20% for each out of network primary care doctor office visit. You pay $20 for each specialist visit for Medicare-covered services. You pay 20% for each out of network specialist visit.

(1) Each year, you pay a total of one $110 deductible. (2)If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.


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Benefit Category

Original Medicare





8 - Doctor Office Visits - continued

See #32 - Routine Physical Exams for more information. If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details.

See #32 - Routine Physical Exams for more information. If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part B coverage. This will not include laboratory tests. Please contact your plan for further details.

9 - Chiropractic Services

You pay 20% of Medicare-approved amounts. (1)(2) You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers. You pay 100% for routine care.

You pay $35 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). You pay 30% of the cost for out of network chiropractic services.

You pay $20 for each Medicare-covered visit (manual manipulation of the spine to correct subluxation). You pay 20% of the cost for out of network chiropractic services.

10 - Podiatry Services


You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs. You pay 100% for routine care.

You pay $35 for each Medicare-covered visit (medically necessary foot care). You pay 30% of the cost for out of network podiatry services.

You pay $20 for each Medicare-covered visit (medically necessary foot care). You pay 20% of the cost for out of network podiatry services.

(1) Each year, you pay a total of one $110 deductible. (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.


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Benefit Category

Original Medicare





11 - Outpatient Mental Health Care

You pay 50% of Medicare-approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. (1)(2)

For Medicare-covered Mental Health services, you pay $35 for each individual/group therapy visit. You pay 30% of the cost for out of network Mental Health services. You pay 30% of the cost for out of network Mental Health services with a psychiatrist.

For Medicare-covered Mental Health services, you pay $20 for each individual/group therapy visit. You pay 20% of the cost for out of network Mental Health services. You pay 20% of the cost for out of network Mental Health services with a psychiatrist.

12 - Outpatient Substance Abuse Care


For Medicare-covered services, you pay $35 for each individual/group visit. You pay 30% of the cost for out of network outpatient substance abuse services.

For Medicare-covered services, you pay $20 for each individual/group visit. You pay 20% of the cost for out of network outpatient substance abuse services.

13 - Outpatient Services/Surgery

You pay 20% of Medicare-approved amounts for the doctor. (1)(2)

You pay 20% of outpatient facility charges. (1)(2)

You pay $100 for each Medicare-covered visit to an ambulatory surgical center. You pay $100 for each Medicare-covered visit to an outpatient hospital facility.

You pay 30% of the cost for services at an out of network ambulatory surgical center. You pay 30% of the cost for services at an out of network outpatient hospital facility.

You pay $100 for each Medicare-covered visit to an ambulatory surgical center. You pay $100 for each Medicare-covered visit to an outpatient hospital facility. You pay 20% of the cost for services at an out of network ambulatory surgical center. You pay 20% of the cost for services at an out of network outpatient hospital facility.



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Benefit Category

Original Medicare





14 - Ambulance Services (medically necessary ambulance services)

You pay 20% of Medicare-approved amounts or applicable fee schedule charge. (1)(2)

You pay $100 for Medicare-covered ambulance services. You pay $100 for out of network ambulance services.

You pay $100 for Medicare-covered ambulance services. You pay $100 for out of network ambulance services.

15 - Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.)

You pay 20% of the facility charge or applicable Copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. (1)(2)

You pay 20% of doctor charges. (1)(2) NOT covered outside the U.S. except under limited circumstances.

You pay $50 for each Medicare-covered emergency room visit; you do not pay this amount if you are immediately admitted to the hospital. Worldwide coverage.

You pay $50 for each Medicare-covered emergency room visit; you do not pay this amount if you are immediately admitted to the hospital. Worldwide coverage.

16 - Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.)

You pay 20% of Medicare-approved amounts or applicable Copayment. (1)(2)

NOT covered outside the U.S. except under limited circumstances.

You pay $35 for each Medicare-covered urgently needed care visit. Worldwide coverage.

You pay $35 for each Medicare-covered urgently needed care visit. Worldwide coverage.



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Benefit Category

Original Medicare





17 - Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy)


You pay $35 for each Medicare-covered Occupational Therapy visit. You pay $35 for each Medicare-covered Physical Therapy and/or Speech/Language Therapy visit. You pay 30% of the cost for out of network Occupational Therapy services. You pay 30% of the cost for out of network Physical Therapy and/or Speech language therapy services.

You pay $20 for each Medicare-covered Occupational Therapy visit. You pay $20 for each Medicare-covered Physical Therapy and/or Speech/Language Therapy visit. You pay 20% of the cost for out of network Occupational Therapy services. You pay 20% of the cost for out of network Physical Therapy and/or Speech language therapy services.

18 - Durable Medical Equipment (includes wheelchairs, oxygen, etc.)


You pay 20% of the cost for each Medicare-covered item. You pay 30% of the cost for durable medical equipment purchased out of network.

You pay 20% of the cost for each Medicare-covered item. You pay 20% of the cost for durable medical equipment purchased out of network.

19 - Prosthetic Devices (includes braces, artificial limbs and eyes, etc.)


You pay 20% of the cost for each Medicare-covered item. You pay 30% of the cost for prosthetic devices purchased out of network.

You pay 20% of the cost for each Medicare-covered item. You pay 20% of the cost for prosthetic devices purchased out of network.



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Benefit Category

Original Medicare





20 – Diabetes Self-Monitoring Training and Supplies (includes coverage for glucose monitors, test strips, lancets, and self-management training)


There is no copayment for Diabetes self-monitoring training. You pay 30% of the cost for out of network Diabetes self-monitoring training. There is no copayment for Diabetes supplies. You pay 30% of the cost for each Diabetes Supply item purchased out of network.

There is no copayment for Diabetes self- monitoring training. You pay 20% of the cost for out of network Diabetes self-monitoring training. There is no copayment for Diabetes supplies. You pay 20% of the cost for each Diabetes Supply item purchased out of network.

21 - Diagnostic Tests, X-Rays, and Lab Services

You pay 20% of Medicare-approved amounts, except for approved lab services. (1)(2)

There is no copayment for Medicare-approved lab services.

You pay: • $35 for each Medicare-covered

clinical/diagnostic lab service. • $35 for each Medicare-covered

radiation therapy service. • $35 to $50 for each Medicare-covered

X-ray visit. You pay: • 30% of the cost for each out of

network clinical/diagnostic lab service.

• 30% of the cost for each out of network radiation therapy service.

• 30% of the cost for out of network X-ray services.

You pay: • $20 for each Medicare-covered

clinical/diagnostic lab service. • $20 for each Medicare-covered

radiation therapy service. • $20 to $50 for each Medicare-covered

X-ray visit. You pay: • 20% of the cost for each out of

network clinical/diagnostic lab service.

• 20% of the cost for each out of network radiation therapy service.

• 20% of the cost for out of network X-ray services.



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Benefit Category

Original Medicare





22 - Bone Mass Measurement (for people with Medicare who are at risk)


There is no copayment for each Medicare-covered Bone Mass Measurement. You pay 30% of the cost for each out of network Bone Mass measurement.

There is no copayment for each Medicare-covered Bone Mass Measurement. You pay 20% of the cost for each out of network Bone Mass measurement.

23 - Colorectal Screening Exams (for people with Medicare age 50 and older)


There is no copayment for Medicare-covered Colorectal Screening Exams. You pay 30% of the cost for each out of network Colorectal Screening exam.

There is no copayment for Medicare-covered Colorectal Screening Exams. You pay 20% of the cost for each out of network Colorectal Screening exam.

24 – Immunizations (Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine)

There is no copayment for the Pneumonia and Flu vaccines. You pay 20% of Medicare-approved amounts for the Hepatitis B vaccine. (1)(2)

You may only need the Pneumonia vaccine once in your lifetime. Please contact your doctor for further details.

There is no copayment for the Pneumonia and Flu vaccines. No referral necessary for Medicare-covered influenza and pneumococcal vaccines. No referral necessary for other immunizations. There is no copayment for the Hepatitis B vaccine. You pay 30% of the cost for each out of network Immunization. There is no copay for the following Immunizations received either In Network or Out-Of-Network: Influenza, Pneumococcal and Hepatitis B.

There is no copayment for the Pneumonia and Flu vaccines. No referral necessary for Medicare-covered influenza and pneumococcal vaccines. No referral necessary for other immunizations. There is no copayment for the Hepatitis B vaccine. You pay 20% of the cost for each out of network Immunization. There is no copay for the following Immunizations received either In Network or Out-Of-Network: Influenza, Pneumococcal and Hepatitis B.



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Benefit Category

Original Medicare





25 – Mammograms (Annual Screening) (for women with Medicare age 40 and older)

You pay 20% of Medicare-approved amounts. (2)

No referral necessary for Medicare-covered screenings.

There is no copayment for Medicare-covered Screening Mammograms. You pay 30% of the cost for each out of network Screening Mammogram. No referral necessary for Medicare-covered screenings.

There is no copayment for Medicare-covered Screening Mammograms. You pay 20% of the cost for each out of network Screening Mammogram. No referral necessary for Medicare-covered screenings.

26 - Pap Smears and Pelvic Exams (for women with Medicare)

There is no copayment for a Pap Smear once every 2 years, annually for beneficiaries at high risk. (2)

You pay 20% of Medicare-approved amounts for Pelvic Exams. (2)

There is no copayment for: • Medicare-covered Pap Smears and

Pelvic Exams. • additional Pap Smears and Pelvic

Exams up to 1 Pap Smear(s) and Pelvic Exam(s) every year.

You pay 30% of the cost for each out of network Pap Smear and Pelvic Exam.

There is no copayment for: • Medicare-covered Pap Smears and

Pelvic Exams. • additional Pap Smears and Pelvic

Exams up to 1 Pap Smear(s) and Pelvic Exam(s) every year.

You pay 20% of the cost for each out of network Pap Smear and Pelvic Exam.

27 - Prostate Cancer Screening Exams (for men with Medicare age 50 and older)

There is no copayment for approved lab services and a copayment of 20% of Medicare-approved amounts for other related services. (2)

There is no copayment for Medicare-covered Prostate Cancer Screening exams. You pay 30% of the cost for each out of network Prostate Screening Exam.

There is no copayment for Medicare-covered Prostate Cancer Screening exams. You pay 20% of the cost for each out of network Prostate Screening Exam

(2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you may pay more.


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Benefit Category

Original Medicare





ADDITIONAL BENEFITS (WHAT ORIGINAL MEDICARE DOES NOT COVER) 28 - Outpatient Prescription Drugs

You pay 100% for most prescription drugs.

You pay 100% for most prescription drugs. See page 23 for additional information about Outpatient Prescription Drugs.

You pay 100% for most prescription drugs. See page 23 for additional information about Outpatient Prescription Drugs.

29 – Dental Services

In general, you pay 100% for dental services.



30 - Hearing Services

You pay 100% for routine hearing exams and hearing aids. You pay 20% of Medicare-approved amounts for diagnostic hearing exams. (1)(2)

There is no copayment for hearing aids. You pay: • $35 for each Medicare-covered

hearing exam (diagnostic hearing exams).

• $0 for each routine hearing test up to 1 test(s) every year.

You pay 30% of the cost for out of network hearing exams. You are covered up to $500 for hearing aids every three years.

There is no copayment for hearing aids. You pay: • $20 for each Medicare-covered

hearing exam (diagnostic hearing exams).

• $0 for each routine hearing test up to 1 test(s) every year.

You pay 20% of the cost for out of network hearing exams. You are covered up to $500 for hearing aids every three years.



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Benefit Category

Original Medicare





31 - Vision Services

You are covered for one pair of eyeglasses or contact lenses after each cataract surgery. (1)(2)

For people with Medicare who are at risk, you are covered for annual glaucoma screenings. (1)(2)

You pay 20% of Medicare-approved amounts for diagnosis and treatment of diseases and conditions of the eye. (1)(2) You pay 100% for routine eye exams and glasses.

There is no copayment for the following items: • Medicare-covered eye wear (one pair

of eyeglasses or contact lenses after each cataract surgery)

• Contacts • Lenses • Frames You pay: • $35 for each Medicare-covered eye

exam (diagnosis and treatment for diseases and conditions of the eye).

• $0 for each Routine eye exam, limited to 1 exam(s) every year.

You pay 30% of the cost for out of network eye exams. You are covered up to $100 for eye wear every two years.

There is no copayment for the following items: • Medicare-covered eye wear (one pair

of eyeglasses or contact lenses after each cataract surgery)

• Contacts • Lenses • Frames You pay: • $20 for each Medicare-covered eye

exam (diagnosis and treatment for diseases and conditions of the eye).

• $0 for each Routine eye exam, limited to 1 exam(s) every year.

You pay 20% of the cost for out of network eye exams. You are covered up to $100 for eye wear every two years.

32 - Routine Physical Exams

You pay 100% for routine physical exams.

There is no copayment for routine physical exams. You pay 30% of the cost for each out of network routine physical exam. You are covered up to 1 exam(s) every year.

There is no copayment for routine physical exams. You pay 20% of the cost for each out of network routine physical exam. You are covered up to 1 exam(s) every year.



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Benefit Category

Original Medicare





33 - Health/Wellness Education

You pay 100%. You are covered for the following: • Health Ed Classes • Newsletter • Nutritional Training • Smoking Cessation • Congestive Heart Program • Nursing Hotline • Disease Management

You are covered for the following: • Health Ed Classes • Newsletter • Nutritional Training • Smoking Cessation • Congestive Heart Program • Nursing Hotline • Disease Management

Benefit Category Aetna Golden Choice Plan Option 1 Lehigh, Monroe, Northampton, Schuylkill Counties

Aetna Golden Choice Plan Option 2 Lehigh, Monroe, Northampton, Schuylkill Counties

OPTIONAL SUPPLEMENTAL PACKAGE # 1 Premium and Other Important Information

You pay $24 each month, in addition to your monthly plan premium of $25 and the Medicare Part B premium, for these optional benefits: • Outpatient Prescription Drugs

You pay $64 each month, in addition to your monthly plan premium of $65 and the Medicare Part B premium, for these optional benefits: • Outpatient Prescription Drugs

Outpatient Prescription Drugs

For prescription drugs, you pay for each prescription or refill: • $15 for Generic drugs up to a 30-day supply • 100% of the cost for Brand drugs up to a 30-day supply • $30 for mail order Generic drugs up to a 90-day supply • 100% of the cost for mail order Brand drugs up to a 90-day

supply There is no individual limit on Generic drugs. There is no individual limit on Brand drugs. You must use designated retail pharmacies and mail order to get your prescription drugs.

For prescription drugs, you pay for each prescription or refill: • $15 for Generic drugs up to a 30-day supply • $25 for Formulary Preferred Brand drugs up to a 30-day

supply • $35 for Non-formulary Brand drugs up to a 30-day supply • $30 for mail order Generic drugs up to a 90-day supply • $50 for mail order Formulary Preferred Brand drugs up to a

90-day supply • $70 for mail order Non-formulary Brand drugs up to a 90-

day supply


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Benefit Category Aetna Golden Choice Plan Option 1 Lehigh, Monroe, Northampton, Schuylkill Counties

Aetna Golden Choice Plan Option 2 Lehigh, Monroe, Northampton, Schuylkill Counties

Outpatient Prescription Drugs – continued

See page 24 for additional information about Optional Supplemental Outpatient Prescription Drugs.

There is no individual limit on Generic drugs. There is a $150 limit quarterly for combined Formulary Preferred Brand and Non-formulary Brand prescription drugs. Any unused amounts cannot be carried forward to the next period. Drugs that are covered by Original Medicare do not count toward your prescription drug limit. Plans can calculate the part you pay in different ways. The copayment does not apply toward the plan prescription limit. Please ask Aetna Health, Inc. about how we determine drug costs that count towards these limits. You must use designated retail pharmacies and mail order to get your prescription drugs. See page 24 for additional information about Optional Supplemental Outpatient Prescription Drugs.


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Important Plan Information

How Does the Plan Work? The Aetna Golden ChoiceTM Plan provides three easy ways to access care. Best of all, you do not need a referral. You can: 1. Select a primary care doctor from the Aetna provider directory (you

pay the PCP copayment for each visit) 2. Go directly to any network doctor for covered services (you pay the

specialist copayment for each visit) 3. Go directly to any licensed out-of-network doctor who accepts

Medicare (you pay coinsurance after $150 annual deductible has been met) for covered services

With the Aetna Golden Choice Plan, you are not required to select a primary care doctor. However, if you do, it can help to reduce your out-of-pocket medical expenses. You can select a primary care doctor from a large provider network. Your doctor can become familiar with your unique health care needs, treat you for preventive care and routine illnesses, and, if you need a specialist, can help direct your care. You can select a primary care doctor who is available 24 hours a day, seven days a week by:

using our DocFind® directory of doctors and hospitals on www.aetna.com

referring to the provider directory calling the toll-free Member Services number on your member ID card

In-Network Services The Aetna Golden Choice Plan does not require referrals for covered services. When you need medical care, simply visit any network doctor or specialist and pay the applicable copay, which varies by service. Out-of-Network Services The Aetna Golden Choice Plan also allows you to receive most covered services from any licensed out-of-network doctor who accepts Medicare. When visiting a licensed out-of-network doctor, you will first pay an annual deductible of $150. Afterwards, Aetna will pay up to a

percentage of the Medicare Allowable Charge. You will be responsible for paying the remaining balance of until you reach your annual coinsurance maximum. Once this annual maximum is reached, Aetna will pay 100 percent for covered services administered by licensed out-of-network providers. Certain charges, such as your deductible and precertification penalties, do not apply to this coinsurance maximum. Other limitations may apply. Precertification of Out-of-Network Services You must contact Aetna and precertify, or obtain prior approval of coverage for, certain services received from licensed out-of-network providers. Some of these services include non-emergency inpatient hospitalization and psychiatric care. To precertify an out-of-network benefit with your plan, contact the Aetna Precertification Unit using the number on your member ID card. Note: Failure to precertify may result in a reduced benefit for out-of-network care. You will be required to pay a penalty of up to $1,000 per medical service, or the cost of the service, whichever is less. Please consult your Evidence of Coverage for a complete list of limitations and exclusions, including services you must obtain in network and pre-certification. Post-Stabilization Care If you are admitted to an out-of-network hospital from the emergency room, you will pay your out-of-network deductible and applicable coinsurance. Once you are stabilized, you have the option to move to a network hospital to help reduce your out-of-pocket expenses. You should always discuss your care options with your treating doctor or call Aetna for assistance.


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Injectables and Medicare-Covered Oral Drugs Available to All Aetna Golden Choice Plan Members Under Their Medical Benefit

Prescription Drug Coverage Prescription Drug Discounts – Available to Aetna Golden Choice Plan Option 1 and 2 Members

Injectables and Medicare-covered oral drugs, such as chemotherapy medications, are covered under the medical benefit of the Aetna Golden Choice Plan. Aetna also provides coverage for many injectable medications not covered under the Medicare program.

The products and services described below are neither offered nor guaranteed under the Aetna contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Aetna grievance process.

In-Network You pay a $45 copay, or the cost of the medication, whichever is

less.

If the medication is administered or provided in a doctor’s office, you also pay the applicable office-visit copay.

Aetna Golden Choice Plan members may receive up to 40 percent off retail prices for eligible prescription drugs not covered by the Medicare program. The Reduced Rate Pharmacy discount program is available for the entire contract year, January 1, 2004 - December 31, 2005.

You pay a maximum of one $45 copay plus the applicable office-visit copay if more than one medication is provided during a doctor’s office visit.

1. To receive eligible drug discounts, simply take your prescription and ID card to any pharmacy participating in our Reduced Rate Pharmacy Discount Program Network. To find network pharmacies use the DocFind® tool at www.aetna.com, refer to the provider directory, or call the Member Services number on your member ID card. You pay the discounted charge directly to the pharmacy. There are no reimbursements to wait for and no claims forms to complete.

Out-of-Network: You pay coinsurance per medication. If a medication is administered or provided in a non-network doctor’s office, you also pay the applicable office-visit coinsurance. Note: Only injectables and Medicare-covered oral drugs are covered out of network. All other outpatient drugs covered under the plan must be obtained in network, except in emergency situations.

The following injectable medications are not covered under the medical benefit by Aetna or under the Medicare program.

Prices for purchased medications are established in contracts between Aetna and each pharmacy or chain organization and are based on the Average Wholesale Price (the published price set by the manufacturer). The exact discount percentage varies by drug and by pharmacy, and not all drugs are available at a discount off retail prices. In some cases, you may be able to obtain a more favorable price than our negotiated charge. This can also vary by pharmacy.

List of 2005 Injectable Medications Excluded from the Medical Benefit GENERIC NAME (BRAND NAME) • Alprostidil (Edex/Caverject)

• Calcitonin (Miacalcin) The cost of your medication is based on Aetna’s negotiated charge with network pharmacies and does not reflect or include any rebates Aetna receives from drug manufacturers.

• Etanercept (Enbrel) • Interferon alfacin-1 (Infergen) • Interferon beta-1a (Rebif)

• Somatren/Somatropin (Protropin,Genotropin, Humatrope, Norditropin, Nutropin, Saizen, Serostim)

• Sumatriptan (Imitrex)


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Please see below for details on how you can receive coverage for generic or brand medication with Optional Supplemental Benefits that are now available under these plans.

With this Optional Supplemental Benefit, for a 30-day supply of covered medications received through a network retail pharmacy, you pay:

• $15 copay for generic medications with no annual maximum. Optional Supplemental Benefits

Since we know that having adequate coverage for the rising costs of prescription drugs is important to Medicare recipients, Aetna is giving members enrolled in the Aetna Golden Choice Plan the option of choosing additional prescription drug coverage. Optional Supplemental Benefits are available at an additional monthly premium.

• $25 copay for preferred (formulary) brand medications until you reach your quarterly brand maximum.

• $35 copay for non-preferred (non-formulary) brand medications until you reach your quarterly brand maximum.

• $150 quarterly maximum for covered brand medications (both preferred and non-preferred brand medications). Once your brand maximum is reached, you pay Aetna’s negotiated charge with the network pharmacy for covered brand medications.

Available with Aetna Golden Choice Plan Option 1 Generic Prescription Drug Optional Supplemental Benefit Aetna Golden Choice Plan members enrolled in Option 1 have the option of purchasing coverage for unlimited generic drugs for a cost of $24 per month, in addition to your monthly plan premium.

The quarterly maximum is the highest dollar amount Aetna will pay per calendar quarter for covered brand prescription drugs. Any unused amounts cannot be carried forward to the next quarter. The quarterly brand maximum is based upon the Aetna negotiated charge with the network pharmacy, and does not include or reflect any rebates received by Aetna from the drug manufacturers.

This benefit provides an unlimited annual benefit for covered generic medication at a network retail pharmacy for a $15 copayment for each 30-day supply. For covered brand-name drugs, you pay 100% coinsurance based on the Aetna negotiated charge. Available with Aetna Golden Choice Plan Option 2 Brand-Name Drug Optional Supplemental Benefit

Mail Order Drugs This optional supplemental benefit provides coverage for generic and brand-name medication. Aetna uses a Preferred Drug list (formulary). This means that the amount you pay for covered brand-name drugs will depend on whether the drug is on the Aetna Preferred Drug list. Brand-name drugs included on Aetna's Preferred Drug list (formulary) are referred to as “preferred drugs”. Non-formulary brand drugs that are covered are referred to as "non-preferred drugs”. Coverage for medications is subject to the terms and limitations of your plan. This optional supplemental benefit costs $64 per month, in addition to the monthly plan premium.

Quantities greater than a 30-day supply of medications are only covered if obtained through mail order and will be delivered right to your door. You save the cost of one retail copayment when you order a 31- to 90-day supply of covered medications through a network mail-order pharmacy (if authorized by your doctor). You’ll receive a mail-order kit with all the information you need to place an order after you enroll, or you may call the Member Services number on your member ID card for an order form.


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What is a formulary? • A formulary is a list of preferred drugs. Brand-name medications are

included in Aetna’s Preferred Drug list (formulary). • Medications on the Preferred Drug list have been approved by the

Food and Drug Administration (FDA) as safe and effective and are considered cost-effective by Aetna.

• Many medications on the Preferred Drug list are subject to manufacturer rebate arrangements between Aetna and the manufacturer of those medications.

As an Aetna Golden Choice Plan member, you have an open formulary, which means your pharmacy benefit covers medications that are on the Preferred Drug list, as well as many that are not. Drugs that are not on the Preferred Drug list are called non-formulary drugs in section II of this Summary of Benefits. After you enroll, you will receive a copy of the Preferred Drug List, which lists our formulary medications. You can also review the list online at www.aetna.com. The drugs on the Preferred Drug list may change during the year. To receive covered pharmacy benefits, take your prescription and ID card to any network pharmacy. Our network includes thousands of pharmacies nationwide. To find network pharmacies, use DocFind® at www.aetna.com, refer to the provider directory, or call the Member Services number on your member ID card. Brand-Name vs. Generic Medications Generic drugs must meet the same FDA standards for safety and effectiveness as their brand counterparts. Generic drugs must:

• Contain the same active ingredients as the brand equivalent • Have the same amount of active ingredients as the brand

equivalent • Carry the same label information as the brand equivalent

Important Prescription Drug Information Prescription drugs in the limitations and exclusions section of the Aetna Golden Choice Plan Evidence of Coverage, as well as nonprescription drugs, are not covered. Medical exceptions for coverage are not available. A partial list of drugs that are not covered under the

prescription drug benefit include: items such as medical supplies, devices and equipment; test agents and devices (except when used for testing diabetes); medication determined to be experimental and/or investigational; drugs used for sexual dysfunction, performance and lifestyle-enhancing medications; medication to promote hair growth; vitamins; smoking-cessation aids; and drugs used for the purpose of weight reduction. Reminder: This plan does not cover any drug that does not, by federal or state law, require a prescription (i.e., an over-the-counter (OTC) drug), even when a prescription is written, or any prescription drugs for which an equivalent over-the-counter product is available. How to Elect an Optional Supplemental Benefit It’s easy to elect an Optional Supplemental Benefit. First, review the information within this Summary of Benefits and select the Aetna Golden Choice Plan that is best for you. If you wish to enroll in an Optional Supplemental Benefit available under your Aetna Golden Choice Plan, select the optional benefit in Section 3 of the enrollment form. Remember to include the additional monthly premium for the optional benefit you select on the enrollment form. If you are a current Aetna Medicare Advantage member and you wish to enroll in an Optional Supplemental Benefit, you must complete a Plan Change Form. For more information, call Member Services at 1-800-282-5366 (TYY 1-800-628-3323) 8 a.m. to 5 p.m. Monday through Friday. Evidence of Coverage The Evidence of Coverage document provides members with a complete list of benefits, including limitations, exclusions, applicable cost sharing, such as copays and coinsurance, and plan rules. This document is provided upon enrollment and once annually thereafter. If you’re a current member, your 2005 Evidence of Coverage will be mailed directly to you at a later date.


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Plan Exclusions and Limitations The following is a partial listing of exclusions and limitations under the Aetna Golden Choice Plan. For a complete list, please refer to your Evidence of Coverage.

• Plastic or cosmetic surgery, unless medically necessary • Custodial care • Experimental procedures or treatments beyond Original Medicare limits • Sexual dysfunction, performance and lifestyle-enhancing prescription drugs and drugs not prescribed for a medical condition • Routine foot care that is not medically necessary

Health and wellness education programs do not involve classroom training and are only provided through Aetna and our network providers. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. After enrollment, consult your Evidence of Coverage to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan. In case of a conflict between your Evidence of Coverage and this information, the Evidence of Coverage will govern. All the terms and conditions of your plan or program are subject to applicable laws, regulations and policies. All benefits are subject to coordination of benefits. You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A if applicable. You can use providers in or out of the network. Providers must be licensed and eligible to receive payment under the federal Medicare program. Higher costs, including copays, deductibles and/or coinsurance, apply for out-of-network services. Certain services require precertification, or prior approval of coverage. Benefits are provided or administered by Aetna Health Inc. or Corporate Health Insurance Company. Coverage is provided through a Medicare Advantage organization with a Medicare contract and benefits, limitations, service areas and premiums are subject to change on January 1 of each year.

Translation of this material into another language may be available. For assistance, please call Member Services at 1-800-282-5366/TDD: 1-800-628-3323.

Puede estar disponible la traduccion de este material en otro idioma. Por favor, para ayuda llame a Servicios al iembro al

1-800-533-6615/TDD: 1-800-628-3323.


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NOTES:


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summary of benefits - aetna · summary of benefits aetna golden choice™ plan january 1, 2005 –...

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