AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

Preventive Hearing Exam Expenses.................................................................................. 54
Hospice Care Expenses..................................................................................................... 55
Outpatient Short-Term Rehabilitation Expense Coverage ................................................. 56
Prescription Drugs.............................................................................................................. 57
Filing Claims................................................................................................................. 60
Claims Appeal Procedures........................................................................................... 61
External Review ........................................................................................................... 62
Non-Surgical Weight Loss Programs/Smoking Cessation ................................................. 62
Spinal Disorder Treatment Benefit ..................................................................................... 63
Other Medical Expenses.................................................................................................... 63
Complex Imaging Services ................................................................................................ 64
National Medical Excellence Program (NME) .................................................................... 64
Travel Expenses .......................................................................................................... 64
Lodging Expenses........................................................................................................ 64
Travel and Lodging Benefit Maximum.......................................................................... 65
Limitations ....................................................................................................................65
Weight Management.......................................................................................................... 65
Limitations.......................................................................................................................... 66
Preventive Mammogram .............................................................................................. 66
Preventive Screening for Cancer ................................................................................. 66
Mouth, Jaws and Teeth................................................................................................ 66
Emergency Room Treatment ....................................................................................... 68
Treatment By An Urgent Care Provider ....................................................................... 68
Treatment of Alcoholism, Drug Abuse, or Mental Disorders ........................................ 69
General Exclusions................................................................................................................ 70