aetna advantage plans for individuals, families and the ... · when you choose aetna as your health...

A Guide toUnderstanding Your Choices andSelecting a QualityHealth Insurance Plan

Aetna Advantage Plans forIndividuals, Families andthe Self-EmployedArizona

13.02.305.1-AZ (8/06)

They say that nothing is more important than your health.

They’re right. And that’s what makes health insurance such an essential part ofyour life — even if you’re not on anemployer’s group insurance plan. In fact,especially if you’re not on a group plan, youneed to take charge of your health…andyour health insurance needs.

At Aetna, we’re here to help. Perhaps you’ve just left a group plan. Or you’relooking for an option other than COBRA.

You may want to switch from your currentindividual health insurance. Or you’re notcurrently insured. Maybe you’ve just receivedanother big rate increase and you’re lookingfor something more affordable. Whateveryour situation, you should know that Aetnaoffers a variety of quality health insuranceplans for individuals and their families inArizona.

So, are you a new graduate or a newlywed?Self-employed or between jobs? An emptynester or early retiree? Wherever you are inlife, we make it easy for you to understand

your choices and select a quality healthplan. We’ll guide you through theprocess and help you choose the righthealth insurance for your personalneeds.

Why Aetna?

When you choose Aetna as your healthinsurance provider, you’re gaining a lotof advantages. Among them:

Easy to understand. Yes, insurance can be simple. We provideyou with straightforward language andeasy-to-understand benefits.

Easy to choose. We’ll guide you and help you selectfrom plans designed to fit your personalsituation. Aetna’s participating providernetwork offers you a wide selection ofphysicians and hospitals.

Easy to afford. Because we offer a variety of premiumpayment options, you choose howmuch to spend: in premiums versus out-of-pocket expenses.

Easy to manage. Thanks to easy-to-use Web-based tools,you can get valuable health andbenefits-related information, quicklylocate Aetna network physicians in your area, and manage your account —right online!

Aetna makes it easy for you tochoose a health insurance plan

Have questions?

Just call 1-800-694-3258,or email us [email protected].

We’re here to help!

Want a quote now?

Visitwww.aetnaindividual.comor call 1-800-MY-Health (1-800-694-3258).

1

n Get a quote and apply online, if you wish, by visitingwww.aetnaindividual.com Then:1) Choose your state.2) Use the helpful information

and tools to choose the best plan for you.

3) Click “Get A Quote.”4) Apply online and submit an

electronic form of payment. (Or mail the enclosed enrollmentform with one (1) form of payment selected.)

5) Track the status of your enrollmentform by clicking the site’s Apps tab.

How to use this booklet

When we say we’re going to make health insurance easy for you, we mean it. This booklet will walk you through theinformation you need to make a smartdecision. Here are the steps you might want to take:

1) Read about Aetna’s health insuranceplans for individuals, starting on page 3.

2) What’s going on in your life right now? The answer can help youchoose a plan, starting on page 4. (If you just want to cut to the chase, theat-a-glance plan comparison chart onpage 10 can help you quickly determineyour health insurance priorities.)

3) Review each plan’s specific features, anddetermine which ones are most importantto you, starting on page 11.

4) Follow the enrollment instructions on this page, then complete and mail the enclosed enrollment form, or apply online atwww.aetnaindividual.com

It’s easy to apply by mail or online!

We make it easy for you to apply for one of our Aetna Advantage Plans for Individuals.

n Complete and mail the enclosedenrollment form, with one (1) form of payment selected to: Aetna Advantage Plans, F230, P.O. Box 61516, King of Prussia, PA 19406-0916.

n Email us [email protected] you have questions, would like to discuss your own unique situation, orwant a rate quote.


The Arizona counties where AetnaAdvantage Plans are offered:

Cochise

Maricopa

Pima

Pinal

Santa Cruz

Aetna’s Arizona Service Area*

Maricopa

Pinal

Pima

SantaCruz

Cochise

PPO Plans available in these counties only.

*Networks may not be available in all zip codes and are subject to change.

Is your doctor in the network?Which local physicians, hospitals,pharmacies and eyewear providersparticipate in the Aetna AdvantagePlan network? Use Aetna’s onlineDocFind® tool at www.aetna.com/docfind/custom/advplans. If youdon’t have Internet access, just call 1-800-MY Health (1-800-694-3258)and ask for a directory of providers.

2

3

High-Deductible PPO Plans(HSA-Compatible)

With the Arizona High-Deductible PPOhealth insurance plan, you’ll pay lowerpremiums in exchange for higher annualdeductibles — at least $2,750 for individualsand $5,500 for families. A key advantage ofthis health insurance plan is that it can bepaired with a Health Savings Account (HSA),a special account that lets you pay forqualified medical expenses with tax-advantaged funds.

What does “tax-advantaged” mean? Itmeans you or an eligible family member can make contributions to your HSA tax-free. Those dollars earn interest tax-free. And when you make withdrawals to pay for qualified health care expenses, they’retax-free, too.

An HSA has other advantages as well.Among them:

n You own your HSA, so even if you changejobs or health insurance plans, the moneyin your account is yours to keep.

n Any money remaining in your HSA at theend of the year rolls over to the next year.You don’t lose it.

n You can withdraw money directly fromyour HSA to cover qualified expenses. Or, you can allow the account to growover time and use it to help pay for futurehealth-related expenses — like long-termcare insurance premiums, COBRApremiums and certain retiree expenses.

Child Only CoverageAll of the Advantage plans in Arizona areavailable for Child only. That is, you maychoose to enroll your child even if noother family member enrolls. Coverageincludes immunizations, well child visits,emergency room and dental preventiveservices (if dental is selected).

Note that if one of the HSA plans isselected for Child only enrollment, anHSA account is not available for the child.

Dental PPO Max Plan

With the Aetna Advantage Dental PPOMax insurance plan, you can obtainservices from either a participating ornon-participating dentist. Participatingdentists have agreed to provide servicesat a negotiated rate for both coveredservices, as well as non-coveredservices such as cosmetic toothwhitening and orthodontic care, soyou generally pay less out-of-pocket. Youalso have the flexibility to visit a dentistwho does not participate in Aetna’snetwork, though you will not benefitfrom negotiated fees.

We offer a variety of Aetna Advantagehealth coverage plans in Arizona. Your Aetna Advantage plan choices are:

PPO Plans

With the Arizona PPO health insuranceplans, you can visit any doctor or hospitalyou choose. (Your out-of-pocket costs willbe lower if you select a provider fromAetna’s wide network of participatingphysicians and hospitals.) In addition, thereare no claim forms to fill out when you visita network provider, and no referrals arerequired to see a specialist.

Preventative and HospitalCare PlansThe Preventative and Hospital Care Plans areideal for individuals that are primarilylooking for affordability when selecting acoverage option. This plan provides inpatienthospital coverage coupled with limitedbenefits for outpatient surgery, skillednursing or home health care charges in lieuof hospitalization. In addition, these plansprovide coverage for preventive careincluding annual GYN exam, well child careand physical exam every 24 months. Thedeductible on the Preventative and HospitalCare Plan applies to most covered expenses.NOTE: This plan provides limited benefitsonly and does not constitute acomprehensive health insurance plan. Assuch, it may not cover all the expensesassociated with your health care needs.

Choose the Aetna Advantage planthat best fits your needs

How do I establish a Health SavingsAccount?For Health Savings AccountEnrollment materials, after enrollingin an Aetna HSA-compatible HighDeductible Health Plan, please call 1-800-MY Health (1-800-694-3258) or visit Aetna’s website atwww.aetnaindividualhsa.com to view and download the materials.


4

Life changes. Very quickly. And as it does,

so do your priorities. What was all fine and good

yesterday may not be appropriate today.

The circumstances of your life can determine the

type of health coverage you need. That’s why

Aetna Advantage Plans for Individuals have been

designed to fit people in specific places in life.

So, do any of these descriptions sound like you?

So, what’s going onin your life?

5

New Graduate?

First, congratulations! Ready to conquer the world? Thinking big thoughts? Well, one of those thoughts should be about health coverage. Since you’re probably on a budget, you might want to look for an affordable policy with low monthly payments and modest out-of-pocket costs. Let us be your guide.


Here are some options that may be right for you.

If you use only basic health careservices and want to keep yourmonthly payments low, consider:

PPO 5000

Preventative and Hospital Care 1250

Preventative and Hospital Care 3000(HSA-Compatible)

If you visit the doctor often and don’t want to pay a lot for thesevisits, consider:

PPO 500

PPO 1500

If you want a balanced mix of low cost and high coverage levels,consider:

PPO 1500

PPO 2500

6

Raising A Family?

Children tend to visit thedoctor more than adults do.So you may be looking forhealth coverage with low feesfor office visits, low monthlypayments, and caps on yourout-of-pocket expenses. Andof course, you can benefitfrom quality preventive carefor your entire family.

All of the Advantage plans in Arizona are available for Child only. That is, youmay choose to enroll yourchild even if no other familymember enrolls. Coverageincludes immunizations, wellchild visits, emergency roomand dental preventive services(if dental is selected).

Note that if one of the HSA plans is selectedfor Child only enrollment, an HSA account isnot available for the child.

Getting Married?

If you’re reconsidering yourhealth coverage needs, you’renot alone. Most newlyweds aredoing the same thing. Sinceyou’re probably on a pretty tightbudget, you may want anaffordable plan with lowmonthly payments — but alsoone that provides for qualitypreventive care, prescriptiondrug coverage, and financialprotection to help safeguardyour assets.

Here are some options that may be right for you.

If you use only basic health careservices and want to keep your monthly payments low…

PPO 5000

If you’re looking to balance low cost andquality coverage, consider:

PPO 1500

PPO 2500

If robust coverage is more important toyou than the lowest possible cost,consider:

PPO 500

7

Here are options that may be right for you.

If you use only basic health careservices and want to keep your monthly payments low …

PPO 5000



If you’re seeking a balance of low costand quality coverage, consider:

PPO 1500

PPO 2500

Between Jobs?

While you’re lining up your nextcareer move, you may want moreaffordable health coverage withlow monthly costs — but alsothat covers you for hospital staysand emergencies. There may bebetter alternatives than COBRA,and we’re here to help guide youthrough them.

Here are some plans that may suit you.

If you use only basic health care services and want to keep your monthly payments low …

PPO 5000

If you don’t want to pay a lot forfrequent doctor visits for you and thekids, consider:

PPO 500

PPO 1500

If robust coverage is more important to you than the lowest possible cost,consider:

PPO 500

Early Retiree?

Congratulations! It may betime for travel, leisure,maybe even starting abusiness. You may needguidance and affordablehealth coverage for you andyour spouse, focusing on bothyour health needs and yourfinancial security. Looking forcoverage for preventive care,hospital inpatient/outpatientservices and emergency care?

Here are options that maysuit you.

If you use only basic health care services and want to keep your monthly payments low, consider:

PPO 5000



Self-Employed?

If you’re on your own, you’veprobably discovered by now that health coverage isn’t cheap.But you know it’s necessary to protect yourself and yourbusiness. Since you’re footing the bill, affordability is likely a priority. We offer plans thatprovide quality hospitalizationand preventive care coverage,with monthly payments thatwon’t consume your profits.

Here are some options youmay want to consider.

If you use only basic health care services andwant to keep your monthly payments low,consider:

PPO 5000



If you want to cap the amount you’ll spend on total medical expenses each year, consider:

PPO 500

PPO 1500

If robust coverage is more important toyou than the lowest possible cost, consider:

PPO 500

If you want a plan that works with anHSA, consider+:

High-Deductible PPO 1 (HSA-Compatible)



+ For information on HSA’s, please refer to page 3

8

If you want to cap the amount you’llspend on total medical expenses eachyear, consider:

PPO 500

PPO 1500

If robust coverage is more important to you than the lowest possible cost,consider:

PPO 500





Empty Nester?

When the kids leave home, youhave endless adventures beforeyou. What are your plans? Travel?Leisure? Reassessing your healthcoverage needs? We can helpwith the latter. You may belooking for a policy that combinesfinancial security with qualitycoverage, such as preventive carecoverage, hospital inpatient/outpatient service and emergencycare, from a plan that will followyou in your travels.

Here are options you maywant to consider.

If you use only basic health care services and want to keep your monthly payments low…

PPO 5000



If you want to cap the amount you’ll spend on total medical expenses each year, consider:

PPO 500

PPO 1500

If robust coverage is more important toyou than the lowest possible cost,consider:

PPO 500





9

FEATURES/BENEFITS COMPARISON*

Very Low Low ModerateModerately

High High

**Feature/Benefits Comparison is based on analysis of Aetna Advantage Plans with 10/1/06 effective dates. For more information on benefit levels, please refer to the benefit pages and/or the plan design documents.

PPO 500Monthly paymentsOut-of-pocket expensesAnnual deductible




High-Deductible PPO 1Monthly paymentsOut-of-pocket expensesAnnual deductible

High-Deductible PPO 2Monthly paymentsOut-of-pocket expensesAnnual deductible

Preventative and Hospital Care1250Monthly paymentsOut-of-pocket expensesAnnual deductible

Preventative and Hospital Care 3000(HSA-Compatible)Monthly paymentsOut-of-pocket expensesAnnual deductible

An at-a-glance comparison of Aetna’s plans

10

This chart gives you a quick, at-a-glance look at all of Aetna’sAdvantage Plans for individuals in Arizona. It will help you determineyour priorities and compare three keyfeatures across all the plans:

n Your payments, or premiums

n What you can expect to pay out of your pocket for services andtreatment (as opposed to what theplan pays for)

n Your annual deductible — that is,how much you’ll pay out of pocketbefore the plan begins covering your expenses

Which one of our plans isright for you? A lotdepends on your priorities.Do you want to keep yourpayments, or “premiums,”as low as possible? Or areyou willing to pay a littlemore each month to helpminimize your out-of-pocket costs for services?

An at-a-glance comparison of Aetna’s plans


11

ARIZONA AETNA ADVANTAGE PLAN OPTIONS

* Maximum applies to combined in and out of network benefits.** Maternity and pregnancy related expenses are not covered. + Payment for out-of-network facility care is determined based upon Aetna’s Allowable Fee Schedule. Payment for other out-of network care is determined based

upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider.A summary of exclusions is listed on page 17 of the Aetna Advantage Brochure.

MEMBER BENEFITS

Deductible IndividualFamily

Coinsurance(Member’s responsibility)

Coinsurance Maximum IndividualFamily

Lifetime Maximum*per insured

Non-specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist)

Specialist Visit**

Hospital Admission**

Outpatient Surgery

Emergency Room(after deductible)

Annual Routine Gyn Exam(Annual Pap/Mammogram)

Preventive Health (Annual Physical)($200 per calendar year*)

Lab/X-Ray

Skilled Nursing (in lieu of hospital)(30 days per calendar year*)

Physical/Occupational Therapy andChiropractic Care(24 visits per calendar year*)

Home Health Care(30 visits per calendar year*)

Durable Medical Equipment($2,000 per calendar year*)

PHARMACYGeneric (Contraceptives Included)

Calendar Year Deductible per Individual

Preferred Brand/Non-Preferred Brand (Contraceptives Included)

Calendar Year Maximum per Individual*

PPO 500 PPO 1500

In-Network Out-of-Network+

$1,500 $3,000$3,000 $6,000

20% after 50% after deductible deductible

$3,000 $4,500$6,000 $9,000

$5,000,000

$20 Copay 50% after not subject deductibleto deductible




$100 Copay (waived if admitted)coinsurance 20%






(Aetna will pay a maximum of $25 per visit.)



$15 Copay $15 Copay plusnot subject 50% not subject to deductible to deductible

$250 (does not apply to generic)

$25/$40 Copay $25/$40 Copay after deductible plus 50%

after deductible

$5,000 $5,000

PPO 2500


$2,500 $5,000$5,000 $10,000


$5,000 $7,500$10,000 $15,000

$5,000,000














$15 Copay $15 Copay plusnot subject 50% not subject to deductible to deductible



after deductible

$5,000 $5,000


$500 $1,000$1,000 $2,000


$2,000 $2,500$4,000 $5,000

$5,000,000














$15 Copay $15 Copay plus not subject 50% not subjectto deductible to deductible



after deductible

$5,000 $5,000

12

ARIZONA AETNA ADVANTAGE PLAN OPTIONS

MEMBER BENEFITS

Deductible IndividualFamily

Coinsurance(Member’s responsibility)

Coinsurance Maximum IndividualFamily

Lifetime Maximum*per insured

Non-specialist Office Visit (General Physician, Family Practitioner, Pediatrician or Internist)

Specialist Visit**

Hospital Admission**

Outpatient Surgery

Emergency Room(after deductible)


Preventive Health (Annual Physical)($200 per calendar year*)

Lab/X-Ray


Physical/Occupational Therapy andChiropractic Care(24 visits per calendar year*)


Durable Medical Equipment($2,000 per calendar year*)

PHARMACYGeneric (Contraceptives Included)

Calendar Year Deductible per Individual

Preferred Brand/Non-Preferred Brand (Contraceptives Included)

Calendar Year Maximum per Individual*

PPO 5000


$5,000 $10,000$10,000 $20,000


$7,500 $12,500$15,000 $25,000

$5,000,000














$15 Copay $15 Copay plusnot subject 50% not subjectto deductible to deductible


$25/$40 Copay $25/$40 Copay plusafter deductible 50% after

deductible

$5,000 $5,000

HIGH DEDUCTIBLE PPO 1 (HSA COMPATIBLE)


$2,750 $5,500$5,500 $11,000

20% after 50% afterdeductible deductible

$5,000 $10,000 $10,000 $20,000

$5,000,000 per member lifetime






0% 50% afternot subject deductibleto deductible

$20 copay 50% afternot subject deductibleto deductible







$15 copay $15 copay after plus 50% after deductible deductible

Integrated Medical/RX deductible

$25/$40 copay $25/$40 copay after plus 50% afterdeductible deductible

$5,000 $5,000

HIGH DEDUCTIBLE PPO 2 (HSA COMPATIBLE)


$5,000 $10,000$10,000 $20,000


$5,000 $10,000 $10,000 $20,000

$5,000,000 per member lifetime






0% 0% afternot subject deductibleto deductible

$25 copay 0% afternot subject deductibleto deductible







0% after 0%after afterdeductible deductible

Integrated Medical/RX deductible


$5,000 $5,000

* Maximum applies to combined in and out of network benefits.** Maternity and pregnancy related expenses are not covered. + Payment for out-of-network facility care is determined based upon Aetna’s Allowable Fee Schedule. Payment for other out-of network care is determined based

upon the negotiated charge that would apply if such services or supplies were received from a Preferred Provider.A summary of exclusions is listed on page 17 of the Aetna Advantage Brochure.

13

ARIZONA AETNA ADVANTAGE PLAN OPTIONS EFFECTIVE 10/1/06

* Maximum applies to combined in and out of network benefits.** Once two members of the Family each meet their individual

calendar year deductibles, from then on each other member ofthe family will be considered to have met their deductibles forthe calendar year.

*** Discount card available+ Payment for out-of-network facility care is determined based

upon Aetna’s Allowable Fee Schedule. Payment for other out-of network care is determined based upon the negotiatedcharge that would apply if such services or supplies werereceived from a Preferred Provider.

++ Once two members of a family reach their individual PaymentLimit in a Calendar Year, benefits will be payable for all familymembers at 100% (copays will still apply) for Covered MedicalExpenses incurred by all family members during the rest of thatCalendar Year. Deductible does not apply to CoinsuranceMaximum.

A summary of exclusions is listed on page 17 of the AetnaAdvantage Brochure.

MEMBER BENEFITS

Deductible Individual

Deductible Family

Coinsurance (Member’s responsibility)

Coinsurance MaximumIndividualFamily

Lifetime Maximum* per insured

Non-Specialist Office Visit(General Physician, Family Practitioner Pediatrician or Internist)

Specialist Visit

Hospital Admission

Outpatient Surgery

Emergency Room (after deductible)


Maternity

Preventative Health (Physical-every 24 months*) ($200 per exam)

Lab/X-Ray


Physical/Occupational/Chiropractic Services/Speech Therapy


Durable Medical Equipment

PHARMACY

Pharmacy Deductible per individual

Generic(Oral Contraceptives Included)

Preferred Brand

Non-Preferred Brand(Oral Contraceptives Included)

Calendar Year Maximum per Individual


$1,250 $2,500

2 Person Max.** 2 Person Max.**

20% 50%after deductible after deductible

$2,500 $5,0002 Person Max.++ 2 Person Max.++

$5,000,000 $5,000,000

Not Covered Not Covered




$100 Copay (waived if admitted) 20%

$35 Copay 50%not subject after deductibleto deductible








Not Covered*** Not Covered***





PREVENTATIVE AND HOSPITALCARE 3000 (HSA-COMPATIBLE)

PREVENTATIVE AND HOSPITAL CARE 1250


$3,000 $6,000

$6,000 $12,000

20% 50% after deductible after deductible

$5,000 $10,000$10,000 $20,000

$5,000,000 $5,000,000





$100 Copay (waived if admitted)20%














14

Access to negotiated discounts: members are eligible to receive non covered services, including cosmetic services such as tooth whitening, at the PPOnegotiated rate when visiting a participating PPO dentist at any time. Nonpreferred (Out-of-Network) Coverage is limited to a maximum of the Plan’s payment, which is based on the contracted maximum fee for participating providersin the particular geographic area. Above list of covered services is representative. Full list with limitations as determined by Aetna appears on the plan booklet/certificate.All products not available in all counties. Please refer to the state map located on page 2 of the Aetna Advantage Brochure.A summary of exclusions is listed on page 17. For a full list of benefit coverage and exclusions refer to the plan documents.

INDIVIDUAL DENTAL PPO MAX PLAN

ARIZONA AETNA ADVANTAGE PLAN OPTIONS EFFECTIVE 10/1/06

MEMBER BENEFITS PREFERRED NONPREFERRED

Annual Deductible per Member $25; $25;(Does not apply to Diagnostic and Preventive Services) $75 family maximum $75 family maximum

Annual Maximum Benefit Unlimited Unlimited

DIAGNOSTIC SERVICES

Oral Exams

Periodic oral exam 100% not subject to deductible 50% not subject to deductible

Comprehensive oral exam 100% not subject to deductible 50% not subject to deductible

Problem-focused oral exam 100% not subject to deductible 50% not subject to deductible

X-rays

Bitewing — single film 100% not subject to deductible 50% not subject to deductible

Complete series 100% not subject to deductible 50% not subject to deductible

PREVENTIVE SERVICES

Adult cleaning 100% not subject to deductible 50% not subject to deductible

Child cleaning 100% not subject to deductible 50% not subject to deductible

Sealants — per tooth Discount Not Covered

Fluoride application — with cleaning 100% not subject to deductible 50% not subject to deductible

Space maintainers Discount Not Covered

BASIC SERVICES

Amalgam filling — 2 surfaces 100% after deductible 50% after deductible

Resin filling — 2 surfaces anterior Discount Not Covered

Oral Surgery Discount Not Covered

Extraction – exposed root or erupted tooth Discount Not Covered

Extraction of impacted tooth —soft tissue Discount Not Covered

MAJOR SERVICES

Complete upper denture Discount Not Covered

Partial upper denture (resin base) Discount Not Covered

Crown — Porcelain with noble metal Discount Not Covered

Pontic — Porcelain with noble metal Discount Not Covered

Inlay — Metallic (3 or more surfaces) Discount Not Covered

Oral Surgery

Removal of impacted tooth — partially bony Discount Not Covered

Endodontic Services

Bicuspid root canal therapy Discount Not Covered

Molar root canal therapy Discount Not Covered

Periodontic Services

Scaling & root planing — per quadrant Discount Not Covered

Osseous surgery — per quadrant Discount Not Covered

ORTHODONTIC SERVICES Discount Not Covered

Aetna Advantage Plans include specialprograms* with a wealth of features to complement our standard healthinsurance coverage. These programs include substantial savings on products and educational materials geared towardyour special health needs. Here are a few of the ways we can help you be well.

Fitness Program. Enjoy reduced membership rates atparticipating health clubs, as well asdiscounts on home exercise equipment.

Eyecare Savings Program. The Vision One** discount program offers special savings on eye exams, contact lenses, frames, lenses, LASIK eyesurgery, and eye care accessories.

Alternative Health Care Program.Receive reduced rates on visits toacupuncturists, chiropractors, massage therapists and nutrition counselors, as well as discounts on vitamins and supplements.

Informed Health® Line. Get answers 24/7 to your healthquestions via this toll-free hotlinestaffed by a team of registered nurses.

Aetna Rx Home Delivery®.With this optional program, orderprescription medications through ourconvenient and easy-to-use mail order pharmacy. To learn more or obtain order forms, visitwww.AetnaRxHomeDelivery.com.

Aetna Resource Connection. Aetna’s Resource Connection providesour individual and self-employed clientswith access to resources and discountsthat can help them build a healthierbusiness. Whether it’s purchasing officesupplies, finding an effective payrollservice or upgrading your IT systems,Aetna Resource Connection can help.Simply put, we’re placing the power ofa Fortune 100 company in the hands ofeach client we serve.

Aetna Navigator™It’s easy and convenient for Aetnamembers to manage their healthbenefits. Anytime – day or night –wherever they have Internet access,members can log in to Aetna Navigator, Aetna’s secure memberwebsite. Members who register on thesite can check the status of their claims,contact Aetna Member Services,estimate the costs of health careservices, and much more!

For more information on any of theseprograms, please visit us online atwww.aetna.com.

* Availability varies by plan. Talk with your Aetna representative for details.

** Vision One is a registered trademark of Cole Vision Corporation.

Aetna Advantage Plan programsto help you be well


15

To qualify for an Aetna Advantage Plan, you must be:

n Under age 64 3/4 (If applying as a couple,both you and your spouse must be under64 3/4.)

n Under age 19 for dependent children

n Between ages 19 and 22 for unmarrieddependent children with proof of full-timestudent status

n Legal residents in a state with productsoffered by the Aetna Advantage Plans

n Legal U.S. residents for at least 6 continuous months.

Medical underwriting requirementsn The Aetna Advantage Plans are not

guaranteed issue plans and require medicalunderwriting. Some individuals can befederally eligible under the HealthInsurance Portability Accountability Act(HIPAA) for a special guaranteed issue planunder Arizona laws and regulations.

n All applicants, enrolling spouses anddependents are subject to medicalunderwriting to determine eligibility andappropriate level of coverage.

n We offer various levels of coverage basedon the known and predicted medical riskfactors of each applicant.

Levels of coverage and enrollmentn You may be enrolled in your selected plan

at the standard premium charge.

n You may be enrolled in your selected plan at a higher rate, based on medical findings.

n You may be declined coverage based onsignificant medical risk factors.

Duplicate coveragen If you are currently covered by

another carrier, you must agree todiscontinue the other coverage priorto or on the effective date of theAetna Advantage Plan.

Pre-existing conditionsn During the first 12 months following

your effective date of coverage, nocoverage will be provided for thetreatment of a pre-existing conditionunless you have creditable priorcoverage.

n A pre-existing condition is an illness or injury for which medical advice ortreatment was recommended orreceived within 6 months precedingthe effective date of coverage.

Terms of coverageYour rates are guaranteed not toincrease for 12 months from youreffective date! Final rates are subject to underwriting review.

Coverage remains in effect as long asyou pay the required premium chargeson time, and as long as you maintainmembership eligibility. Coverage will be terminated if you become ineligibledue to any of the followingcircumstances:

n Non-payment of premiums

n Residency requirements

n Obtaining duplicate coverage

n For other reasons permissible by law

Things You Need to Know to Enroll

All You Need to Know AboutEasy-PaySimple Automatic Payments viaElectronic Funds Transfer (EFT)

Simple registration n Complete the payment section of the Aetna

Advantage Plans enrollment form. Initialpayment can be made with EFT. Yourpayment will be deducted upon approval ofthe enrollment form.

Invoices for EFT Accountsn You will not receive a paper invoice when

you are enrolled in EFT. Payments willappear on your bank statement as “AetnaAutodebit Coverage.”

Terminating EFTn To terminate EFT, you will need to provide

Aetna with 10 days written notice prior to thedate your next EFT payment will be deducted.

n Without this written notice, your bankaccount may be debited for the nextmonth’s premium. You will then need tocontact Aetna to have funds placed back inthe checking account.

Refunds on EFT Accountsn To process an EFT refund (placing money back

in member’s checking account), Aetna willrequire at least 5 days after the withdrawalwas made to ensure valid payment.

Rejected EFT Transactionsn If the EFT payment rejects for any reason,

Aetna will automatically terminate the EFTand send you a letter saying you will receivepaper invoices. Processing time to reinstateEFT will be 30–60 days.

n If an EFT payment is rejected, you will need topay that payment by paper check or credit card.

Timing for EFTn Payments for Cycle 1 accounts (1st of the

month effective date) will be taken fromyour bank account between the 3rd andthe 10th of the month the premium is due.

n Payments for Cycle 2 account (15th of themonth effective date) will be taken fromyour bank account between the 18th and23rd of the month the premium is due.

16

MedicalThese medical plans do not cover all healthcare expenses and include exclusions andlimitations. Members should refer to theirplan documents to determine which healthcare services are covered and to what extent.The following is a partial list of services andsupplies that are generally not covered.However, your plan documents may containexceptions to this list based on statemandates or the plan design or rider(s)purchased.

Services and supplies that are generally notcovered include, but are not limited to:

n All medical and hospital services notspecifically covered in, or which arelimited or excluded by your plandocuments, including costs of servicesbefore coverage begins and aftercoverage terminates

n Cosmetic surgery

n Custodial care

n Donor egg retrieval

n Weight control services including surgicalprocedures for the treatment of obesity,medical treatment, and weightcontrol/loss programs

n Experimental and investigationalprocedures, (except for coverage formedically necessary routine patient carecosts for Members participating in acancer clinical trial)

n Charges in connection with pregnancycare other than for pregnancycomplications

n Immunizations for travel or work

n Implantable drugs and certain injectabledrugs including injectable infertility drugs

n Infertility services including artificialinsemination and advanced reproductivetechnologies such as IVF, ZIFT, GIFT, ICSI andother related services unless specifically listedas covered in your plan documents

n Medical expenses for a pre-existingcondition are not covered for the first 365 days after the member’s effectivedate. Lookback period for determining a pre-existing condition (conditions forwhich diagnosis, care or treatment wasrecommended or received) is 6 monthsprior to the effective date of coverage. If the applicant had prior creditablecoverage within 63 days immediatelybefore the signature on the application,then the pre-existing conditions exclusionof the plan will be waived.

n Nonmedically necessary services or supplies

n Orthotics

n Over-the-counter medications and supplies

n Radial keratotomy or related procedures

n Reversal of sterilization

n Services for the treatment of sexualdysfunction or inadequacies includingtherapy, supplies or counseling

n Special or private duty nursing

n Therapy or rehabilitation other than thoselisted as covered in the plan documents

n Mental health in-network services for PPO plans not covered, except for severe biologically based mental ornervous disorders

DentalListed below are some of the charges and services for which these dentalplans do not provide coverage. For acomplete list of exclusions andlimitations, refer to plan documents

n Dental Services or supplies that areprimarily used to alter, improve orenhance appearance. Negotiated ratesfor cosmetic procedures available whena participating dentist is accessed.

n Experimental services, supplies or procedures

n Treatment of any jaw joint disorder,such as temporomandibular jointdisorder

n Replacement of lost or stolenappliances and certain damagedappliances

n Those services that Aetna defines asnot necessary for the diagnosis, care ortreatment of a condition involved

n All other limitations and exclusions inyour plan documents

10-day right to reviewDo not cancel your current insuranceuntil you are notified that you havebeen accepted for coverage.

We’ll review your application todetermine if you meet underwritingrequirements. If you’re denied, you’ll benotified by mail. If you’re approved,you’ll be sent an Aetna Advantage Plancontract and ID card.

If, after reviewing the contract, you findthat you’re not satisfied for any reason,simply return the contract to us within 10days. We will refund any premium you’vepaid (including any contract fees or othercharges) less the cost of any services paidon behalf of you or any covereddependent.

Arizona Limitations and Exclusions

17


The Aetna Advantage Plans for Individuals and families are offered, underwritten oradministered by Aetna Life Insurance Company through an out-of-state blanket trust.

If you need this material translated into another language, please call Member Servicesat 1-866-565-1236.

Si usted necesita este material en otro lenguaje, por favor llame a Servicios al Miembro al 1-866-565-1236.

This material is for information only and is not an offer or invitation to contract. Plan features andavailability may vary by location. Plans may be subject to medical underwriting or other restrictions.Rates and benefits may vary by location. Investment services are independently offered through JPMorgan Institutional Investors, Inc., a subsidiary of JP Morgan Chase Bank. Providers areindependent contractors and are not agents of Aetna. Provider participation may change withoutnotice. Aetna does not provide care or guarantee access to health services. Not all health servicesare covered. See health insurance plan documents for a complete description of benefits,exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetnareceives rebates from drug makers that may be taken into account in determining Aetna’sPreferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for coveredprescriptions. Information is subject to change.

For more information about Aetna plans, refer to www.aetna.com.

13.02.305.1-AZ (8/06) ©2006 Aetna Inc.


aetna advantage plans for individuals, families and the ... · when you choose aetna as your health...

Documents