AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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unless a generic substitute is not available. For each new or refilled prescription, you simply pay the Copayment or Coinsurance shown in the <strong>Benefits</strong> Summary. When drugs are purchased at a pharmacy, the Prescription Drug program will allow up to a 34-day supply. If you need a brand name drug and a generic equivalent drug is available you will be charged the difference in ingredient cost between the brand and generic drug, in addition to the brand Copayment. Maintenance drugs (to treat long-term or chronic medical conditions) can be obtained by mail through a CVS Caremark Mail Service Pharmacy. This program allows you to save money by receiving a 90-day supply of medication for a low Copayment or Coinsurance. COVERED DRUGS The following are covered drugs unless listed as an exclusion below: • Federal Legend Drugs • State Restricted Drugs • Compounded Medications of which at least one ingredient is a legend drug • Insulin • Needles and Syringes • OTC Diabetic Test Strips and Lancets • Retin-A through age 25 • Tazorac cream through age 25 • Zostavax * • Pediatric Fluoride Vitamins* • Legend Pediatric Fluoride Vitamin Drops up to a 50-day supply • Inhalers, Assisted Devices *Age limit may apply under medical or dental benefit PRIOR AUTHORIZATION REQUIRED The following drugs are covered only after CVS Caremark receives prior authorization from your Physician: • Retin-A/Avita/Altinac (cream only) age 26 and older • Tazorac cream age 26 and over • Growth hormones/Growth Hormone Releasing Hormones • Oral Contraceptives (except Emergency Contraceptives) for females only • 91 day Pre-packaged Oral Contraceptives up to a 91-day supply for females only • PDST (Preferred Drug Step Therapy) - For a list of drugs that require PDST, contact CVS Caremark customer service • Transdermal and Intravaginal Contraceptives for females only • Anti-Obesity/Weight Loss Drugs (Legend Anti-Obesity Preparations) • Erythroid Stimulants • <strong>My</strong>eloid Stimulants 58
• Platelet Proliferation Stimulants • MS Agents • Tysabri • Interferons • Xolair • Provigil NOTE: Drugs for cancer therapy and the reasonable cost of administering them are usually covered. The Prescription Drug Plan may implement prior authorization rules to determine if the cancer therapy is eligible for coverage under the Plan based on the plan rules. Certain off-label uses of cancer drugs may not be eligible for coverage under the Plan if there is insufficient published evidence to determine the toxicity, safety and/or efficacy of the cancer therapy for the specific cancer it is prescribed to treat. EXCLUSIONS The following are excluded from coverage unless specifically listed as a benefit under “Covered Drugs”: • Non-Federal Legend Drugs • Contraceptive medications, jellies, creams, foams, devices, implants or injections, whether or not dispensed by prescription, which are purchased or prescribed for the sole purpose of preventing conception, including diaphragms • Emergency contraceptives • Retin-A (except cream) age 26 and older • Non-sedating antihistamines/non-sedating antihistamine combo products (SPECs: Z2O, Z2Q) • Zostavax through age 59 • Drug to treat impotency • Mifeprex • Therapeutic devices or appliances • Drugs whose sole purpose is to promote or stimulate hair growth or for cosmetic purposes only (e.g., Rogain) • Allergy Sera • Biologicals, Immunization agents or Vaccines • Blood or blood plasma products • Drugs labeled "Caution-limited by Federal law to investigational use", or Experimental drugs, even though a charge is made to the Covered Individual • Medication for which the cost is recoverable under any Workers' Compensation or Occupational Disease Law or any State or Governmental Agency, or medication furnished by any other Drug or Medical Service for which no charge is made to the Covered Individual • Medication which is to be taken by or administered to a Covered Individual, in whole or in part, while he or she is a patient in a licensed Hospital, rest home, sanitarium, extended care facility, skilled nursing facility, Convalescent Facility, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals 59
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AETNA PPO PLAN SUMMARY PLAN DESCRIP
Page 3 and 4:
Women’s Health and Cancer Rights
Page 5 and 6:
PURPOSE This document, along with o
Page 7 and 8:
COBRA Continuation coverage as requ
Page 9 and 10:
• Scientific data such as control
Page 11 and 12: A service or supply is not Medicall
Page 13 and 14: charge Aetna determines to be the p
Page 15 and 16: URGENT CONDITION This means a sudde
Page 17 and 18: CONTINUATION OF COVERAGE FOR ILL ST
Page 19 and 20: During Annual Open Enrollment, you
Page 21 and 22: • Change in marital status, inclu
Page 23 and 24: • The last day of the pay period
Page 25 and 26: • CHIP participant; or • Depend
Page 27 and 28: SPECIFIC INFORMATION ABOUT YOUR COB
Page 29 and 30: notified of the Social Security Adm
Page 31 and 32: USERRA CONTINUATION COVERAGE If you
Page 33 and 34: Privacy of Health Information HIPAA
Page 35 and 36: Coverage will be provided in a mann
Page 37 and 38: not submitted sufficient informatio
Page 39 and 40: The notice of Adverse Benefit Deter
Page 41 and 42: Determination concerns an admission
Page 43 and 44: 4) Assisting in Plan’s Reimbursem
Page 45 and 46: EMPLOYEE RETIREMENT INCOME SECURITY
Page 47 and 48: IMPORTANT INFORMATION ABOUT THE PLA
Page 49 and 50: COVERED MEDICAL EXPENSES The Plan p
Page 51 and 52: necessary for the diagnosis or trea
Page 53 and 54: URGENT CARE COPAY A separate Urgent
Page 55 and 56: OUTPATIENT SURGICAL EXPENSES Covere
Page 57 and 58: LIMITATIONS TO HOME CARE EXPENSES C
Page 59 and 60: Not included are charges for: • A
Page 61: Short-term rehabilitation is therap
Page 65 and 66: Effective July 1, 2011 (or such lat
Page 67 and 68: • Services for weight loss render
Page 69 and 70: COMPLEX IMAGING SERVICES Covered Ex
Page 71 and 72: Surgery, during which the Covered I
Page 73 and 74: • For root canal therapy; • For
Page 75 and 76: GENERAL EXCLUSIONS GENERAL EXCLUSIO
Page 77 and 78: • Those for or in connection with
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AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

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