AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

PLAN ADMINISTRATOR
Trinity Health
PLAN YEAR
The Plan Year is the 12-month period beginning on January 1 and ending on the following December 31.
You have the opportunity to change your medical coverage during the Annual Open Enrollment period
before the new Plan Year begins.
PREFERRED CARE
This is a health care service or supply furnished by a person’s Primary Care Physician or any other Preferred
Care Provider. Also furnished by a person’s Primary Care Physician prior to treatment and a Non-Preferred
Urgent Care Provider when travel to a Preferred Urgent Care Provider for treatment is not feasible. Preferred
Care is also care, which is recommended and approved by the BHCC.
PREFERRED CARE PROVIDER
This is a health care provider that has contracted to furnish services or supplies for a Negotiated Charge; but
only if the provider is, with Aetna’s consent, including in the directory as a Preferred Care Provider for the
service or supply involved; and the class of associates of which you are member.
PRESCRIPTION DRUG
Those drugs approved by the Food and Drug Administration of the United States which require a written
prescription by a Physician or Dentist and which bear the legend, “Caution: Federal law prohibits
dispensing without a prescription.”
PRIMARY CARE PHYSICIAN
This is the Preferred Care Provider who is selected by a person from the list of Primary Care Physicians in
the directory, is responsible for the person’s on-going health care; and is shown on Aetna’s records as the
person’s Primary Care Physicians.
PROVIDER
A person (such as a Physician) or a facility (such as a Hospital) that provides services or supplies related
to medical care.
• Trinity Health Facilities – Trinity Health’s facilities, its Ministry Organization’s Hospitals and satellite
locations.
• Network Providers – Hospitals, Physicians and other licensed facilities or Health Care Professionals
who have contracted with Aetna to provide services to members enrolled in a PPO health care Plan.
Network Providers have agreed to accept Aetna’s approved amount as payment in full for Covered
Services.
• Nonparticipating (Out-of-Network) Providers — Providers who are not part of the Aetna PPO
provider Network. Out-of-Network Providers have not signed participation agreements with Aetna
agreeing to accept the Aetna payment as payment in full. However, nonparticipating Providers may
agree to accept the Aetna approved amount as payment in full on a per claim basis. However,
because these Providers are not a part of the PPO Network, you must pay higher out-of-pocket costs.
R.N.
This means a registered nurse.
REASONABLE CHARGE
The Reasonable Charge for a service or supply is the lowest of the Provider’s usual charge for furnishing it;
and the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same
or a similar service or supply and the manner in which charges for the service or supply are made; and the
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