Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Arizona Small Group
Enrollment Guide
Your Aetna plan features,
and how to sign up
Plans effective January 1, 2015
www.aetna.com
14.02.304.1-AZ J (9/14)
What’s your healthy?
At Aetna, we put you at the
center of everything we do.
You can count on us to provide
tools and programs that help
you find your healthy.
Health benefits and health insurance plans are offered, underwritten and/or administered by Aetna Health Inc., Aetna
Health Insurance Company and/or Aetna Life Insurance Company (Aetna). Each insurer has sole financial responsibility for
its own products.
Welcome to Aetna!
Whatever your healthy is, we can help you get there. Everyone’s
healthy is different. For your family, how you define your
healthy may include what’s healthy for your budget too. We
understand that, and that’s why we provide multiple health
benefits and health insurance plans that can help you reach
your healthy while keeping your financial health on track too.
With Aetna, you can choose the path that gets you closer
to your healthy. Whether your goal is lower monthly
premiums, lower out-of-pocket costs at doctor’s visits or
easy access to out-of-network care, we have plans that
will work hard for you.
We know that part of everyone’s healthy is knowing that
you’re making smart choices when it comes to your health
care. So we give you the power to do that at every step along
the way. Find a doctor online, check the status of a claim
and compare out-of-pocket costs before you go. Our tools
and resources help make sure your family’s well-being is
always well-coordinated. And you’ll have the right tools to
manage your health care for a healthier you. Let’s work
together to find your healthy.
Table of Contents
Aetna Navigator® secure member website
4
Aetna health care transparency tools
5
Personal Health Record 6
®
RelayHealth 7
Informed Health® Line 8
Urgent care
8
Special programs for the special needs of women
8
At home products discounts
9
Book discounts
9
Fitness discounts
9
Hearing discounts
10
Natural products and services discounts
10
Oral health care discounts
10
Vision discounts
11
Weight management discounts
11
Preventive care
12
Aetna Health Connections SM disease
management program
12
Medical products
13
Aetna Whole Health® options
15
Dental products
23
Vision products
25
Life and disability insurance
29
Getting to know your Aetna prescription drug plan 30
Limitations and exclusions
32
Find a doctor or specialist
35
How to complete the enrollment form application 36
Your member ID card
37
Contact information
38
3
Aetna Navigator®
secure member website
When you need up-to-date information about your health
benefits or insurance plan or want information about a
particular health condition, here’s where you’ll find it!
And, if you’re interested in learning more about a particular
health condition, Aetna Navigator provides credible health
information resources.
Your secure Aetna Navigator website is a single source for
online health and benefits information. It’s convenient,
and easy to use:
•Simple Steps To A Healthier Life® interactive online health
and wellness program helps you turn knowledge about your
health into action for making positive health changes with:
--Online Health Assessment
--Tailored Health Reports
--Personalized Action Plan and online wellness programs
--Easy-to-find health information, resources and tools
1. Go to www.aetna.com.
2. Click on Log In/Register.
3. Register as a new user, or log in using your secure user
name and password.
4. Find a wealth of credible health care information and
self-service functions — available to you any time of the
day or night — from wherever you have Internet access.
Your secure website lets you:
•View information about who is covered on your plan
•Get an ID card
•Find doctors, pharmacies or hospitals with our DocFind®
search tool
•Check the status of a claim or review an Explanation
of Benefits (EOB)
•Contact Member Services with benefits questions
(also available in Spanish)
Use Aetna Navigator’s online tools to manage your benefits
and help you make more informed health decisions:
•Hospital Comparison tool helps you decide where
to receive care for specific procedures, conditions and
diagnoses. You can compare hospitals based on four
factors you consider important:
1. Number of patients treated per year
2. Complication rates
3. Mortality rates
4. Length of stay
•Price-A-DrugSM tool* helps you estimate the cost
of prescriptions before you buy
•Estimate the Cost of Care tool provides average
in- and out-of-network costs for certain procedures
based on a geographic area
•Pharmacy benefits summary allows you to locate
retail pharmacies; order prescriptions through the Aetna
Rx Home Delivery ® mail-order pharmacy; search and
learn about medications; and review the medications
available in the Aetna formulary
4
*If included in your plan.
•Aetna SmartSourceSM search tool delivers relevant health
information that’s specific to you, based on where you
live, your Aetna health plan, and other information.
Aetna SmartSource scans our vast resources to bring you,
in a single search:
--Specialists in your local area
--Related medications, treatment options and estimated
health costs
--Aetna programs that may help you manage your condition
--Easy-to-understand health articles and tips
•Aetna InteliHealth® interactive consumer website for
credible health, dental and wellness information provided
by Harvard Medical School
•Healthwise® Knowledgebase, a user-friendly online
information tool that lets you research your own issues and
preferences for health information. It also has interactive
and streaming videos about topics such as asthma and
heart health
Health care transparency tools
You can make more informed health care decisions by
using our online transparency tools before visiting a doctor
or hospital.*
To access our health care transparency tools, log in to
Aetna Navigator. Click on Cost of Care from the home page.
There, you can use the easy online instructions to:
Our transparency tools allow you to:
•Check rates for doctors and specialists for common
treatments and procedures.
•Compare hospital costs side by side.
•Get personalized cost estimates to find out what you’ll pay
before you go.
•View and compare rates for participating doctors.
•Look up costs for medical procedures at facilities in select
locations around the country and quickly identify medical
specialists who are high performers in their field based on
clinical quality and efficiency.**
•Use at your convenience since the information is available
24/7 through Aetna Navigator, our secure member website,
and DocFind®, our online directory of doctors and facilities.
*Always consult your doctor about your health care decisions. Members cannot view rates for dentists, vision providers or certain
types of health care professionals with these tools.
**Clinical quality and efficiency information is based on Aexcel® designation for specialists in 12 specialty categories. You can learn
more about our Aexcel designation in our Understanding Aexcel brochure available under the Learn More section of DocFind. We
regularly upgrade our tools to provide the latest cost and clinical quality and efficiency information about our network providers.
5
Personal Health Record
Put your Personal Health Record to work and make history
As an Aetna medical plan member, you’ll have access to your
Personal Health Record*.
Portability ensures your personal health records
go where you go
Your Personal Health Record is a secure online tool that
makes it easy to:
Our relationship with Microsoft provides our members
portability of their personal health information. You can
transfer a copy of your Aetna Personal Health Record from
Aetna Navigator directly to Microsoft HealthVault at
www.healthvault.com/personal. Your information will be
stored on this secure, web-based consumer health platform
and remains available if you change jobs or health plans.
•Keep your health information in a single, safe place.
•Track doctor visits, prescriptions and more, for you
and your family.
•Give your doctor a more complete health history.
•Receive timely, personalized health alerts and preventive
care reminders.
Much of your health information is ready
for you to see
Information from your Aetna health claims automatically
appears in your Personal Health Record. And, you can easily
add more information. List your allergies, your family history
and more. It’s up to you. The more you enter, the better
picture you and your doctors will get of your overall health.
Use it to talk to your doctors with ease
The Personal Health Record can help you team up with your
doctors. You can share your Personal Health Record online
with individual doctors by making it available through a
secure website many doctors already use. You can also print
your Health Summary to share at office visits or to help you
fill out medical forms when you see a new doctor.
Stay safe and healthy with alerts and reminders
Your Personal Health Record helps you get the care you need.
If you’re due for a checkup or other important screening, you
might see a reminder when you log in. You can also receive a
message if there’s an alternative treatment that may improve
your care. And, if you give us permission, you can get e-mails
telling you that a new alert or reminder is in your secure
Personal Health Record.
6
You can also print and save a PDF copy of your health record
for your own files through the same Aetna Navigator location.
Print your personalized Emergency Card
You can print an Emergency Information Card that pulls
information from several sections of your Personal Health
Record. It provides first responders with your emergency
contact’s name and phone number, your insurance details,
any medications you are taking, allergies if you have any,
and information about whether you have a living will or have
designated your organs for donation. All this detail in a
printout that folds and fits in your wallet.
Be sure the information in these sections is accurate and up to
date, and start using your Aetna Personal Health Record today!
It’s easy to get started.
Visit your Personal Health Record
today or use our Walk Me Through
guide to explore how this resource
works on your own.
Visit www.aetna.com/showcase/
phr/ for answers to the most
common questions from our
members.
*The Aetna Personal Health Record should not be used as the sole source of information about the member’s health history.
Programs to help you get the right care
RelayHealth®
Visit your doctor online with webVisit®
Our latest innovative health care benefit in collaboration
with RelayHealth offers members “webVisits.” Now you
can communicate effectively and securely online with your
doctor to seek non-urgent medical care. You pay any required
copays or deductibles through the system as if you had made
an office visit.
webVisit is easy to use:
How to get started:
•Click the Register Now link on the RelayHealth website at
www.relayhealth.com/Patients/Registration.aspx
•Once registered, choose an Aetna contracted
RelayHealth provider
Log in at your convenience to take advantage of the many
features available to registered members, in addition to the
webVisit service:
1. Enter the RelayHealth website for non-urgent medical care.
2. Complete a questionnaire.
3. Submit it directly and confidentially to your doctor.
4. Once your doctor reviews your questionnaire, you will get
a diagnosis, instructions and information — just like at an
actual visit.
•Consult with your doctor
•Make and/or cancel appointments
•Obtain referrals
•Request lab and test results
•Order prescription refills
•Send a note to your doctor’s office
Three great reasons to use RelayHealth:
•HIPAA-compliant — secure and authenticated
with user login
•Clinically structured questionnaire focuses
on your symptoms to help your doctor determine
an accurate diagnosis
•Reimbursable — checks eligibility in real time, collects
copayment and submits claim automatically
webVisit through RelayHealth
links you with your doctor,
Aetna health plan and pharmacy
in a single secure network.
Check your service area for availability.
7
Informed Health® Line
Access to a registered nurse — 24/7!
With our Informed Health Line, you can talk to a registered
nurse anytime, day or night. Just call our 24-hour toll-free
number (available upon enrollment). While only your doctor
can diagnose, prescribe or give medical advice, the Informed
Health Line nurses can provide information on thousands of
health topics. They can also tell you how to ask the right
questions and describe health symptoms more effectively
during your next visit to your doctor. Remember, always
contact your doctor first with any questions or concerns
regarding your health care needs.
Urgent care
For care that is not minor, such as fractures, sprains or other
urgent injuries, we contract with urgent care centers to offer
you an economical alternative to visiting an emergency room.
Urgent care sites are staffed with physicians to handle urgent
medical needs. Typically, urgent care centers offer evening
and weekend hours with no appointments needed.
Check your plan design and benefits summary to get more
information about coverage and costs to visit an urgent care
center. To find the closest care center near you, simply log
in to Aetna Navigator, select DocFind and follow the easy
online instructions.
Special programs for the special needs of women
Ongoing health management
Work, family, friends. Too much to do, too little time to do it.
That’s today’s woman. Add health needs that change over
time, and you’ll know why we offer services and information
to help you manage your health.
Prevention programs for women
Our preventive programs can help women benefit from:
•Preventive screening reminders for breast and cervical cancer
•Culturally focused initiatives to help reduce health
disparities among women of diverse ethnic backgrounds
Women’s health online
Go to http://womenshealth.aetna.com for information on
women’s health issues — from heart health, breast cancer
and pregnancy to baby care and other topics important to
women, as well as:
•An interactive body mass index tool
•A pregnancy guide
•USDA Food Plate recommendations
•Information on diet and nutrition
8
For ob/gyn care, no referrals needed
For an annual well-woman exam, unlimited visits for
gynecologic problems and routine maternity care, women
may schedule an appointment with participating obstetrical,
gynecological or women’s health care professionals
without a referral.
Beginning Right® Maternity Program
The Beginning Right Maternity Program offers information
and services to expectant mothers, including care coordination
by obstetrical nurses experienced in preterm labor education,
breastfeeding support and more. We want to make sure
expectant mothers have the information needed to make
informed decisions about health care while pregnant or
planning a pregnancy. Members enrolled in both our medical
and dental plans, along with our Beginning Right Maternity
Program, may also receive enhanced dental benefits
(additional cleaning or treatment of periodontal (gum)
disease, fully covered with no deductible) during pregnancy.
Special maternity care
From the start of pregnancy to birth, our maternity
management program offers expectant mothers services
and educational materials to help give their newborns a
healthy start.
Moms-to-be receive:
•Educational materials, available in English or Spanish,
that cover:
--Prenatal care
--Labor and delivery
--Newborn and baby care
--Breastfeeding
--Postpartum depression
•A pregnancy risk survey and nurse care coordination for
high-risk pregnancies
•A program to help you stop smoking
Member discounts
At home products
Fitness
You can get discounts on products for your home
and family that best fit your needs and your life, such as
Omron Healthcare, Inc. blood pressure monitors.
Regular exercise can help you maintain a healthy weight and
look and feel better. It can also lower your risks for:
Books
You can save on books, DVDs, and more.
•American Cancer Society Bookstore: Save on your
purchase of books, greeting cards and kits.1 Order online
or by phone.
•Mayo Clinic Bookstore: Save on books and DVDs
purchased online.
•Pranamaya: Save on yoga DVDs, CDs, online videos
and books.
•Alzheimer’s disease
•Depression and anxiety
•Diabetes
•Heart disease
•High blood pressure
You can save on gym memberships2 and name-brand home
fitness and nutrition products that support a healthy lifestyle
with services provided by GlobalFit®.
1Includes two or more books combined as a special discount package.
2Participation is for new gym members only. If you belong to a gym now, or belonged recently, call GlobalFit to see if a discount applies.
9
Hearing
Natural products and services
You can take care of your hearing and save money with
Hearing Care Solutions and HearPO®.
You and your family can save on specialty health care
products and services, including online consultations:
Hearing Care Solutions
•A discounted rate on hearing exams
•Hundreds of hearing aid models at low prices
•A two-year supply of batteries (up to 96 cells), then
join a discount battery mail-order program
•Free in-office service of hearing aids for one year
after purchase
•Free routine services (cleanings, checks and battery
door replacements) for the life of the hearing aid
•The ChooseHealthy®1 program: You’ll get a discount
off the normal fee for acupuncture, chiropractic, massage
therapy and nutrition services. And get a discount off
the retail price of health and wellness products.
•Vital Health Network: You can get a discount off the retail
price of an online consultation with a Vital Health Network
doctor for one topic. Then, save more off the retail price of
an online consultation for additional topics.
HearPO
•A discounted rate on hearing exams
•Savings on many hearing aid styles
•A cost break on the newest hearing-aid technologies,
including programmable and digital instruments from
leading manufacturers
•Discounts on hearing aid repairs
•Free follow-up services for one year
•Free batteries (up to 160 cells per hearing aid)
Taking care of your teeth is important. Who doesn’t enjoy a
healthy smile and fresh breath?
Oral health care
You can take care of your teeth and save money on oral
health care products from Epic Dental and Waterpik®.
Epic Dental
You can save on Epic Dental products that contain xylitol,
a natural sweetener that does not cause cavities. In fact, xylitol
has been shown to prevent tooth decay.2 Save on gum, mints,
toothpaste and more.
Waterpik
You can save on Waterpik oral health care products that help
keep your mouth as healthy as it can be.
10
1The ChooseHealthy program is made available through American Specialty Health Administrators, Inc., a subsidiary of American
Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission herein.
2Guideline on Xylitol Use in Caries Prevention. American Academy of Pediatric Dentistry, Council on Clinical Affairs. Vol. 35, No. 6.
2011. Available at: www.aapd.org/media/policies_guidelines/g_xylitoluse.pdf. Accessed March 18, 2014.
Vision
Weight management
You can take care of your vision and save with EyeMed.
Get discounts on:
You can meet your weight loss goals, get healthier and save
money on CalorieKing®, Jenny Craig® and Nutrisystem®.
•Eye exams
•Eyeglass frames and lenses
•Contact lenses and solutions
•LASIK surgery
•Sunglasses (prescription and non-prescription)
•And more!
•CalorieKing®:
--Join an Annual or Monthly CalorieKing Program.
Programs have a seven day free trial period.1
--Then save when you continue your Annual Program
membership.2
--With either an Annual or Monthly Program membership.
Also save on products in the CalorieKing online Store.
•Jenny Craig®
Choose from these offers:
--FREE 30-Day Program3
--Percent off the Jenny All Access Program enrollment fee3
•Nutrisystem®
--Save on any 28-Day Nutrisystem® SuccessTM weight loss
meal plan.4
--Plus, get other offers from Nutrisystem when you
purchase a plan.
Use any eye care provider in the EyeMed nationwide network,
at the following retail chains:
•Lenscrafters®
•Pearle Vision®
•Target Optical®
•Sears Optical® locations
•JCPenney Optical
You also can use any of the thousands of participating
eye doctors in private practices.
You can get these discounts even if you have other vision
benefit coverage. If you do have coverage, check your plan
requirements first.
With all programs and plans, enjoy one-on-one help,
personalized menus, online tools, chat rooms and more.
Visit Aetna Navigator at
www.aetna.com for more details
about all available discounts.
1You can cancel your program membership at any time during the first seven days. Log in to the program and follow the instructions in
“Payment and Account Details” under “Account Settings.” If you do not cancel during the first seven days, your credit card will be
charged on the 8th day.
2If you are already a CalorieKing member and want to get the Aetna discounted membership price, you will need to terminate your
current CalorieKing Account and rejoin.
3Plus the cost of food. Plus the cost of shipping (if applicable). Offer applies to initial enrollment fee only and is valid only at
participating Centers and through Jenny Craig At Home. Each offer is a separate offer and can be used only once per member.
No cash value. Restrictions apply.
4 The Aetna discount offers do not apply to any program in which you are already enrolled. To receive the discounted rate, you must
wait until your current program ends.
11
Prevention programs —
helping you and your family stay healthy
Preventive care
Member health education reminders
Good health begins with prevention. So we’ve developed
an array of wellness programs and services to help you and
your family stay healthy through all the stages of your life.
To help prevent, detect and monitor problems early on,
we mail reminders encouraging you to schedule important
annual health screenings. We also send important health
information, a chart of recommended preventive care
guidelines and a tear-off wallet card to schedule and track
this important information.
Aetna Health ConnectionsSM disease management program
You can work one-on-one with an Aetna nurse, by phone or online, to support and help you manage any of over 35 medical
conditions or diseases. Our nurses can help you understand your condition, stick to your doctor’s treatment plan and so much
more. The program supports these conditions:
Vascular
•Heart failure
•Diabetes –
adult & pediatric
•Coronary artery disease
(CAD)
•Peripheral artery disease
(PAD)
•High blood pressure –
adult & pediatric
•Cerebrovascular
disease/stroke (CVA)
•High cholesterol
12
Pulmonary
•Asthma – adult & pediatric
•Chronic obstructive
pulmonary disease (COPD)
Orthopedic/Rheumatologic
•Osteoporosis
•Osteoarthritis (OA)*
•Rheumatoid arthritis (RA)
•Chronic lower back pain
Gastrointestinal
•Gastro-esophageal reflux
disease (GERD)
•Peptic ulcer disease
•Inflammatory bowel
disease (IBD)
(Crohn’s Disease)
•Chronic hepatitis
Neuro-Geriatric
•Geriatrics
•Migraines
•Seizures
•Parkinsonism
Cancer
•General cancer
•Breast cancer
•Lung cancer
•Lymphoma/leukemia
•Prostate cancer
•Colorectal cancer
*Not scored by Clinical Stratification and Identification (CSID) process.
**Addressed as a comorbid condition.
Renal
•Chronic kidney disease
•End stage renal failure
Other
•Weight management –
adult & pediatric
•Cystic fibrosis –
adult & pediatric
•HIV
•Hypercoagulable state
•Sickle cell disease –
adult & pediatric
•Depression**
Medical products
Pick the health benefits and insurance plan that’s right for
you and your family
HMO*
HNO
PPO
Savings
Plus
Coverage for
preventive care
•
•
•
•
PCP
requirement
•
Referrals
required
•
Plan features
Premium
affordability
scale
•
HMO Network = 18,162 doctors and 95 hospitals
HNO Network = 18,162 doctors and 95 hospitals
PPO Network = 18,401 doctors and 95 hospitals
Savings Plus Network = 11,419 doctors and 46 hospitals
Aetna Whole Health Network featuring:
Banner Health Network = 5,853 providers and 19 hospitals
Out-of-network
access
No in-network
claim forms
AWH
The Aetna provider network has more than 18,000 physicians
and 95 hospitals in Arizona.** So whichever plan you choose,
you will be able to find the provider to best suit your needs.
•
•
•
•
Arizona Care Network = 3,985 providers and 15 hospitals
•
•
•
•
•
$$$$
$$$
$$$
$$
$
Use DocFind to search for health
care providers or select a primary
care physician (PCP).
Savings Plus — same quality local care at a
lower cost
The Aetna Savings Plus plans provide Arizona members who
reside in Maricopa, Pima and Pinal Counties with the same
types of coverage as other Aetna medical plans, but at a lower
premium cost. Savings are generated through the use of the
Savings Plus network, a quality network of local health
care providers.
The plans also:
www.aetna.com/docfind
Call the Member Services
number on your ID card to order
a provider directory.
•Cover doctor’s visits, hospital stays and preventive care
•Include prescription drugs
•Provide access to a secure member self-service website
Aetna Whole HealthSM (AWH) plans featuring
Banner Health Network (BHN) and Arizona Care
Network (ACN)
The Aetna Whole Health plans provide Arizona members
in the greater Phoenix area with the same types of coverage
as other Aetna medical plans, but at a lower premium cost.
Savings are generated through the use of the Aetna
Whole Health network, a quality network of local health
care providers.
*This applies to AWH HMO plans.
**According to the Aetna Enterprise Provider Database as of April, 2014. Network subject to change.
13
Choose the right health plan for you and your
family in three easy steps:
1. How much are you spending?
Evaluate your pay stubs, receipts and canceled checks for
all your medical spending and add the total amount to
the total cost of your premium, copayments, deductibles
and coinsurance. Think about your needs for next year.
Here are some common scenarios:
•Are you or your dependents scheduled for any
surgical procedures?
•Will you be seeing a specialist for a recently
diagnosed condition?
•Are you or your spouse pregnant or planning a pregnancy?
2. What are your choices?
•Check with your company to see which plans are available.
•Compare the premium, deductibles, copayments and
out-of-pocket maximums on each plan.
•Review the limitations on each plan: Chiropractic care,
acupuncture and physical therapy are some common
benefits with limited visits.
3. Choose the right plan.
•Now that you know your health care spending for the past
year and the plan choices offered by your employer,
determine your needs for the coming year.
•Add up what you will pay for premiums, copayments and
deductibles under your new plan based on last year’s
expenses or what you think might happen this year.
•Review the coinsurance maximum amount and decide if it’s
affordable if a major medical condition develops.
•Remember: The most expensive plan is not necessarily the
best one for you and your family.
•Complete the process by submitting the necessary
paperwork and updating your doctors of any changes.
14
Health care terms to know
Premiums are the amount you pay for your insurance
policy, often deducted from your paycheck.
Deductibles are paid out of pocket each year before
your medical plan covers expenses. Each family
member usually has a separate deductible to meet
before the medical plan starts coverage.
Copayments (copay) are flat fees charged each
time you visit the doctor or use certain medical
services, regardless of the cost of the procedure.
Doctor’s visits and pharmaceutical purchases
are often subject to copays.
Coinsurance requires you to pay a percentage of the
cost of the medical services. Most plans require
either a coinsurance or copay — usually not both.
Out-of-pocket limits is the maximum amount you’ll
have to spend before all of your medical bills are
covered by the medical plan. Deductibles, copays,
coinsurance and pharmacy cost accumulate toward
your out-of-pocket limit.
Aetna Whole Health (AWH) options in the Phoenix
metropolitan area*
We’re proud to offer two Accountable Care
Organizations (ACOs) in the greater Phoenix
metropolitan area for you to choose from
Both ACOs are high quality provider networks that are
working with us to help improve care while decreasing costs
for members and employers. Your employees will find care in
their own communities, with local health care providers who
have skill, experience, and compassion.
Both the Arizona Care Network (ACN) and the Banner Health
Network (BHN) provide convenient access to an integrated
network of health care providers and facilities dedicated to
patient-centered team approach that delivers a better patient
experience at a much lower cost.
Two key ingredients make the difference
in our ACOs
•A better health care experience enabled by doctor-driven
care, technology-based information sharing, and care
coordination
•New payment models and incentives that encourage
accountability to help improve patient health
Better health, better care, better cost
That’s what the Aetna Whole Health product with our
ACOs is designed for. It’s a member-centered approach
that may differ from care your employees have had before
•The ACO care team’s goal is to help keep your employees
healthy or help improve their health, not just treat them
when they’re sick or injured
•The ACO care team can better coordinate care because they
can see how other doctors are treating your employees, what
medicine they’re taking, lab results, health history and more
•The ACO care team is up-to-date on medical guidelines
and clinical information. This helps to spot problems early
and develop personalized care plans for your employees
•The ACO team wants your employees to take an active and
informed role in their health and health care decisions
To find an Aetna Whole Health – Arizona
Care Network doctor:
•Visit www.aetna.com/docfind.
•Type a name, specialty, procedure or condition in the “What
are you looking for?” box OR search from a list of conditions,
procedures and provider types.
•Enter your ZIP code or city and state.
•Select the “(AZ) Aetna Whole Health Plan – Arizona Care
Network” health benefits plan from the drop-down menu.
•Look for doctors and facilities with the Aetna Whole Health
symbol.
To find an Aetna Whole Health – Banner
Health Network doctor:
•Visit www.aetna.com/docfind.
•Type a name, specialty, procedure or condition in the “What
are you looking for?” box OR search from a list of conditions,
procedures and provider types.
•Enter your ZIP code or city and state.
•Select the “(AZ) Aetna Whole Health Plan – Banner Health
Network” health benefits plan from the drop-down menu.
•Look for doctors and facilities with the Aetna Whole Health
symbol.
All plans are designed to have two levels of benefits
•Level 1: When members use the designated network to
coordinate all of their care, they realize maximum savings.
•Level 2: Use of any other providers will result in a lower
level of benefits.
*Employers and employee must reside in an eligible area. Live/work rules apply.
15
Arizona Care Network coverage area
Anthem
Glendale
17
60
North Scottsdale
101
Peoria
Scottsdale
Litchfield Park
101
101
202
10
Apache Junction
60
Goodyear
202E
10
Mesa
Maricopa County
Maricopa
San Tan Valley
Gilbert
Pinal County
To find an Aetna Whole HealthSM – Arizona Care
Network doctor:
• Visit www.aetna.com/docfind
• Type a name, specialty, procedure or condition in the
“Who or what are you looking for?” box
• Enter your ZIP code or city and state in the “Where?” box
• Choose (AZ) Aetna Whole Health – Arizona Care Network from the
“Select a Plan” drop-down menu
16
n Aetna Whole Health Banner Network doctor
Hospitals
Primary care physicians
Urgent care facilities
Arizona Care Network coverage area
Hospital
ZIP
City
Address
Arizona Orthopedic Surgical Hospital
85224
Chandler
2905 W Warner Rd.
Chandler Regional Medical Center
85224
Chandler
1955 W Frye Rd.
Mercy Gilbert Medical Center
85297
Gilbert
3555 S Val Vista Dr.
Phoenix Children’s – Mercy Gilbert Center
Specialty Care
85297
Gilbert
3555 S Val Vista Dr.
Arrowhead Hospital
85308
Glendale
18701 N 67th Ave.
HealthSouth Valley of the Sun
Rehabilitation Hospital
85304
Glendale
13460 N 67th Ave.
St. Joseph’s Westgate Medical Center
85305
Glendale
7300 N 99th Ave.
West Valley Hospital Medical Center
85395
Goodyear
13677 W McDowell Rd.
HealthSouth East Valley Rehabilitation Hospital
85206
Mesa
5652 E Baseline Rd.
Arizona Heart Hospital
85016
Phoenix
1930 E Thomas Rd.
Maryvale Hospital
85031
Phoenix
5102 W Campbell Ave.
OASIS Hospital
85008
Phoenix
750 N 40th St.
Paradise Valley Hospital
85032
Phoenix
3929 E Bell Rd.
Phoenix Baptist Hospital
85015
Phoenix
2000 W Bethany Home Rd.
Phoenix Children’s Hospital
85006
Phoenix
1919 E Thomas Rd.
St. Joseph’s Hospital and Medical Center
85013
Phoenix
350 W Thomas Rd.
HealthSouth Scottsdale Rehabilitation Hospital
85260
Scottsdale
9630 E Shea Blvd.
17
Banner Health Network coverage area
Anthem
Wickenburg
17
Glendale
North Scottsdale
60
101
Peoria
Litchfield Park
Scottsdale
101
101
10
Apache Junction
202
60
Goodyear
Mesa
202E
10
Maricopa County
Gilbert
San Tan Valley
Maricopa
Pinal County
18
To find an Aetna Whole HealthSM – Banner Health
Network doctor:
Hospitals
• Visit www.aetna.com/docfind
• Type a name, specialty, procedure or condition in the “Who or what
are you looking for?” box
• Enter your ZIP code or city and state in the “Where?” box
• Choose the (AZ) Aetna Whole Health – Banner Health Network plan
from the “Select a Plan” drop-down menu
Health centers
Primary care physicians
Urgent care facilities
Banner Health Network coverage area
Hospital
Address
Health center
Address
Banner Goldfield
Medical Center
2050 W Southern Ave.
Apache Junction, 85120
Banner Health Center
at Verrado
20751 W Market St.
Buckeye, 85396
Banner Gateway
Medical Center
1900 N Higley Rd.
Gilbert, 85234
Banner Health Center
in Chandler
1435 S Alma School Rd.
Chandler, 85286
Banner Thunderbird
Medical Center
5555 W Thunderbird Rd.
Glendale, 85306
Banner Health Center
in Gilbert
155 E Warner Rd.
Gilbert, 85296
Banner Baywood
Medical Center
6644 E Baywood Ave.
Mesa, 85206
Banner Health Center
at Estrella
9780 S Estrella Pkwy.
Goodyear, 85338
Banner Health Center
in Maricopa
17900 N Porter Rd.
Maricopa, 85138
Banner Health Center
in East Mesa
1917 S Crismon Rd.
Mesa, 85209
Banner Desert
Medical Center
Cardon Children’s
Medical Center
1400 S Dobson Rd.
Mesa, 85202
Banner Heart Hospital
6750 E Baywood Ave.
Mesa, 85206
Banner Health Center
in Queen Creek
21772 S Ellsworth Loop Rd.
Queen Creek, 85142
Banner Estrella
Medical Center
9201 W Thomas Rd.
Phoenix, 85037
Banner Health Center
in Surprise
13995 W Statler Blvd.
Surprise, 85374
Banner Good Samaritan
Medical Center
1111 E McDowell Rd.
Phoenix, 85006
Banner Ironwood
Medical Center
37000 N Gantzel Rd.
San Tan Valley, 85140
Banner Behavioral
Health Hospital
7575 E Earll Dr.
Scottsdale, 85251
Banner Boswell
Medical Center
10401 W Thunderbird Blvd.
Sun City, 85351
Banner Del E. Webb
Medical Center
14502 W Meeker Blvd.
Sun City West, 85375
19
Savings Plus Network Map
10
Maricopa
County
Pinal County
8
Pima County
To find an Aetna Savings Plus doctor:
• Visit www.aetna.com/docfind.
• Type a name, specialty, procedure or condition in the “What are you looking for?”
box OR search from a list of conditions, procedures and provider types.
• Enter your ZIP code or city and state.
• Select the Savings Plus Plans: Savings Plus of Arizona from the drop-down menu.
20
Hospitals
Primary care physicians
Urgent care facilities
Savings Plus Network Map
Hospital
ZIP
City
Address
Casa Grande Regional Medical Center
85122
Casa Grande
1800 E Florence Blvd.
Arizona Orthopedic Surgical Hospital
85224
Chandler
2905 W Warner Rd.
Chandler Regional Medical Center
85224
Chandler
1955 W Frye Rd.
Mercy Gilbert Medical Center
85297
Gilbert
3555 S Val Vista Dr.
Arrowhead Hospital
85308
Glendale
18701 N 67th Ave.
Banner Thunderbird Medical Center
85306
Glendale
5555 W Thunderbird Rd.
St. Joseph¹s Westgate Medical Center
85307
Glendale
7300 North 99th Avenue
West Valley Hospital Medical Center
85395
Goodyear
13677 W McDowell Rd.
Arizona Spine and Joint Hospital
85206
Mesa
4620 E Baseline Rd.
Cardon Children’s Medical Center
85202
Mesa
1400 S Dobson Rd.
Mountain Vista Medical Center
85209
Mesa
1301 S Crimson Rd.
Oro Valley Hospital
85755
Oro Valley
1551 E Tangerine Rd.
North Peoria Emergency Center
85383
Peoria
26900 N Lake Pleasant Pkwy.
Arizona Heart Hospital
85016
Phoenix
1930 E Thomas Rd.
Los Ninos Hospital
85016
Phoenix
2303 E Thomas Rd.
Maryvale Hospital
85031
Phoenix
5102 W Campbell Ave.
OASIS Hospital
85008
Phoenix
750 N 40th St.
Paradise Valley Hospital
85032
Phoenix
3929 E Bell Rd.
Phoenix Baptist Hospital
85015
Phoenix
2000 W Bethany Home Rd.
Phoenix Children’s Hospital
85016
Phoenix
1919 E Thomas Rd.
Phoenix Indian Medical Center
85016
Phoenix
4212 N 16th St.
St. Joseph’s Hospital and Medical Center
85013
Phoenix
350 W Thomas Rd.
St. Luke’s Medical Center
85006
Phoenix
1800 E Van Buren
Surgical Specialty Hospital of Arizona
85015
Phoenix
6501 N 19th Ave.
21
Hospital
22
ZIP
City
Address
Scottsdale Healthcare Greenbaum
Surgical Specialty Hospital
85251
Scottsdale
3535 N Scottsdale Rd.
Scottsdale Healthcare Osborn Medical Center
85251
Scottsdale
7400 E Osborn Rd.
Scottsdale Healthcare Shea Medical Center
85260
Scottsdale
9003 E Shea Blvd.
Scottsdale Healthcare Thompson Peak Hospital
85255
Scottsdale
7400 E Thompson Peak Pkwy.
Tempe St. Luke’s Hospital, A Campus of St. Luke’s 85281
Tempe
1500 S Mill Ave.
Carondelet St. Joseph’s Hospital
85711
Tucson
350 N Wilmot Rd.
Carondelet St. Mary’s Hospital
85745
Tucson
1601 W St. Marys Rd.
Northwest Medical Center
85741
Tucson
6200 N La Cholla Blvd.
Tucson Medical Center
85712
Tucson
5301 E Grant Rd.
University Physicians Hospital at Kino
85713
Tucson
2800 E Ajo Way
Dental products
Choose the right dental benefits and insurance plan* for you
and your family
A healthy body starts with a healthy smile
Research suggests that serious gum disease, known as
periodontitis, may be associated with many health problems.
This is especially true if serious gum disease continues
without treatment.1,2
Now, here’s the good news. Researchers are discovering that
a healthy mouth may be important to your overall health.1,2
Need to find a participating
dentist? Just visit DocFind or
give us a call.
www.aetna.com/docfind
1-877-238-6200
Plan features
Coverage for preventive care
DMO®
PPO
Freedom-of-Choice*
DMO
Freedom-of-Choice*
PPO
•
•
•
•
No primary care dentist requirement
•
•
No referrals
•
•
Out-of-network access
•
•
No claim forms
•
•
No deductibles
•
•
No dollar annual maximums
•
•
*All family members must be enrolled in the same plan.
1MayoClinic.com. “Oral health: A window to your overall health.” Available at www.mayoclinic.com/health/dental/DE00001.
May. 11, 2013 (accessed May 2014.)
2J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):20-8. doi: 10.1016/S1532-3382(12)70006-4. “State of the science: chronic periodontitis
and systemic health.”
23
Pediatric dental/vision (2 to 50)
Pediatric dental and vision mandates are a separate essential
health benefit category and are included with your medical
benefits. Pediatric dental and vision is for children up to age 19.
Pediatric dental*
PPO/HNO plans
Preferred
PPO HSA plans
Nonpreferred
HMO plans
with no
deductible
Indemnity
Preferred
Nonpreferred
Preferred
No network
Dental checkup
(preventive/diagnostic)
0%; deductible 30%;
waived
deductible
waived
0% after
deductible
30% after
deductible
0%
0%; deductible
waived
Dental basic
30% after
deductible
50% after
deductible
30% after
deductible
50% after
deductible
30%
30% after
deductible
Dental major
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50%
50% after
deductible
Dental ortho
(after 24 months
of continuous
coverage)
50% after
deductible
50% after
deductible
50% after
deductible
50% after
deductible
50%
50% after
deductible
Pediatric vision*
PPO/HNO plans
24
PPO HSA plans
Nonpreferred
HMO plans
with no
deductible
Indemnity
Preferred
No network
Preferred
Nonpreferred
Preferred
Vision exam
(one exam per
12 months)
$0 copay;
deductible
waived
50% after
deductible
0%; deductible 50% after
waived
deductible
$0 copay;
deductible
waived
0%; deductible
waived
Frames, lenses or
contacts
(per 12 months)
Preferred:
50% after
0%; deductible deductible
waived
Preferred:
0% after
deductible
Preferred:
0%
Preferred:
0%; deductible
waived
Nonpreferred:
50% after
deductible
Nonpreferred:
50% after
deductible
50% after
deductible
Nonpreferred:
50%
Nonpreferred:
50% after
deductible
*These plans do not cover all vision or dental expenses and have exclusions and limitations. Members should refer to their plan
documents to determine which services are covered and to what extent.
Vision
overview
See why Aetna Vision Preferred is the right choice
for you
Discover the freedom to see any licensed vision
office or retailer
•You can go where you want and buy what you want. In- and
out-of-network benefits are included for most services.
•Customer service and self-service tools available seven days
a week.
•Low out-of-pocket vision expense.
•Value, choice, and convenience. You can choose any frame
available — includes value-priced frames to high-quality
designer frames with no confusing frame towers or
formularies.
•Discounts on additional eyeglass purchases and noncovered
items including LASIK.*
•You will receive a welcome packet that includes a member ID
card, benefit summary and nearest provider locations.
Nearly 60 percent of eyewear dollars in the United States are
spent at optical retailers.2 With Aetna Vision Preferred, you will
have access to one of the largest national networks with over
65,000 vision office and retailers, featuring the most desired
national retailers,3 including LensCrafters®, Pearle Vision®,
Sears® Optical , Target Optical® and JCPenney Optical. Most
with evening and weekend hours, including Sundays and
located in or near shopping centers for added convenience.
Keep an eye on your health
Aetna Vision Preferred offers savings in or out of network for
routine eye exams, contact lenses and eyeglasses, including
prescription sunglasses and designer frames.
We are committed to vision wellness, patient education and
the associated preventive care.
Getting vision care can help lower unnecessary costs and
improve your overall health. During a routine eye exam, all
aspects of vision are checked, including the eye’s structure
and how well the eyes work together. Annual eye exams allow
eye care providers to monitor the health of the eyes and track
changes that can occur from year to year. Besides measuring
vision, eye exams help find early signs of certain chronic
health conditions including diabetes, high blood pressure,
high cholesterol and eye disease.1
Can’t find your provider in our network? No problem. We
provide out-of-network reimbursements for most services
so you are covered no matter who you see for your routine
eye care.
Low out-of-pocket costs
Sample out-of-pocket costs**
Retail price
Out-ofpocket costs
with Aetna
Vision
Preferred
Savings with
Aetna Vision
Preferred
Exam
$114.00
$10.00
$104.00
Frames
$124.41
$0
$124.41
Lenses
$ 83.00
$10.00
$ 73.00
Total
$321.41
$20.00
$301.41
*Discounts may not be available in all states.
**Results will vary for different plan designs. Example does not include premiums.
1Allaboutvision.com/eye-exam/importance.htm, April 2012. Accessed October 2014.
2Jobson Vision Watch, Vision Council Member Benefits Report, June 2011.
3Jobson Consumer Perceptions of Managed Vision Care Report 2011.
25
Aetna Vision Preferred – Premier plan
In network
Out of network
In-network amount represents member copay, plan allowance or fixed discounted fee.
Out-of-network amount represents the maximum reimbursement amount.
Exam – coverage allowed for one eye exam every rolling 12 months
Routine eye exam
$10 copay
$25 reimbursement
Standard contact lens fit/follow
$40 discounted fee
Not covered
Premium contact lens fit/follow
10% off retail
Not covered
Frames – coverage allowed for one eyeglass frame every rolling 12 or 24 months (rates vary by frame frequency)
Any frame available at location
$130 plan allowance
$65 reimbursement
Lens – coverage allowed for one pair of prescription eyeglass lenses every rolling 12 months (in lieu of contact lenses per benefit period)
Single vision lenses
$10 copay
$20 reimbursement
Bifocal vision lenses
$10 copay
$40 reimbursement
Trifocal vision lenses
$10 copay
$65 reimbursement
Lenticular vision lenses
$10 copay
$65 reimbursement
Standard progressive lenses
$75 copay
$40 reimbursement
Premium progressive lenses
20% discount off retail minus $120 allowance
plus $75 copay = member out of pocket
$40 reimbursement
UV treatment
$15 discounted fee
Not covered
Tint (solid and gradient)
$15 discounted fee
Not covered
Standard plastic scratch coating
$15 discounted fee
Not covered
Standard polycarbonate lenses – child to age 19
$40 discounted fee
Not covered
Standard polycarbonate lenses – adult
$40 discounted fee
Not covered
Standard anti-reflective coating
$45 discounted fee
Not covered
Contacts – coverage for one order of contact lenses every rolling 12 months (in lieu of eyeglass lenses per benefit period)
Conventional contact lenses
$115 plan allowance
$80 reimbursement
Disposable contact lenses
$115 plan allowance
$80 reimbursement
Medically necessary contact lenses
$0 copay
$200 reimbursement
Discounts
Available at in network locations
•15 percent off balance over the plan allowance on conventional contact lenses
•20 percent off balance over the plan allowance on frames
•Up to 40 percent off additional pairs of eyeglasses or prescription sunglasses
•15 percent discount off retail or 5 percent discount off the promotional price for LASIK
Laser vision correction or PRK from U.S. Laser Network only. Call 1-800-422-6600
•20 percent off noncovered items, including photochromic/transition and polarized lenses
•Receive significant savings after your lens benefit has been exhausted by ordering
replacement contact lenses online at www.aetnavision.com
26
Discounts may not be available in all states.
Aetna Vision Preferred – Plus plan
In network
Out of network
In-network amount represents member copay, plan allowance or fixed discounted fee.
Out-of-network amount represents the maximum reimbursement amount.
Exam – coverage allowed for one eye exam every rolling 12 months
Routine eye exam
$10 copay
$25 reimbursement
Standard contact lens fit/follow
$40 discounted fee
Not covered
Premium contact lens fit/follow
10% off retail
Not covered
Frames – coverage allowed for one eyeglass frame every rolling 12 or 24 months (rates vary by frame frequency)
Any frame available at location
$130 plan allowance
$65 reimbursement
Lens – coverage allowed for one pair of prescription eyeglass lenses every rolling 12 months (in lieu of contact lenses per benefit period)
Single vision lenses
$25 copay
$10 reimbursement
Bifocal vision lenses
$25 copay
$25 reimbursement
Trifocal vision lenses
$25 copay
$55 reimbursement
Lenticular vision lenses
$25 copay
$55 reimbursement
Standard progressive lenses
$90 copay
$25 reimbursement
Premium progressive lenses
20% discount off retail minus $120 allowance
plus $90 copay = member out of pocket
$25 reimbursement
UV treatment
$15 discounted fee
Not covered
Tint (solid and gradient)
$15 discounted fee
Not covered
Standard plastic scratch coating
$0 copay
$15 reimbursement
Standard polycarbonate lenses – child to age 19
$0 copay
$35 reimbursement
Standard polycarbonate lenses – adult
$40 discounted fee
Not covered
Standard anti-reflective coating
$45 discounted fee
Not covered
Contacts – coverage for one order of contact lenses every rolling 12 months (in lieu of eyeglass lenses per benefit period)
Conventional contact lenses
$130 plan allowance
$90 reimbursement
Disposable contact lenses
$130 plan allowance
$90 reimbursement
Medically necessary contact lenses
$0 Copay
$200 reimbursement
Discounts
Available at in network locations
•15 percent off balance over the plan allowance on conventional contact lenses
•20 percent off balance over the plan allowance on frames
•Up to 40 percent off additional pairs of eyeglasses or prescription sunglasses
•15 percent discount off retail or 5 percent discount off the promotional price for LASIK
Laser vision correction or PRK from U.S. Laser Network only. Call 1-800-422-6600
•20 percent off noncovered items, including photochromic/transition and polarized lenses
•Receive significant savings after your lens benefit has been exhausted by ordering
replacement contact lenses online at www.aetnavision.com
Discounts may not be available in all states.
27
Aetna Vision Preferred – Basic plan
In network
Out of network
In-network amount represents member copay, plan allowance or fixed discounted fee.
Out-of-network amount represents the maximum reimbursement amount.
Exam – coverage allowed for one eye exam every rolling 12 months
Routine eye exam
$20 copay
$20 reimbursement
Standard contact lens fit/follow
$40 discounted fee
Not covered
Premium contact lens fit/follow
10% off retail
Not covered
Frames – coverage allowed for one eyeglass frame every rolling 12 or 24 months (rates vary by frame frequency)
Any frame available at location
$100 plan allowance
$50
Lens – coverage allowed for one pair of prescription eyeglass lenses every rolling 12 months (in lieu of contact lenses per benefit period)
Single vision lenses
$20 copay
$15 reimbursement
Bifocal vision lenses
$20 copay
$30 reimbursement
Trifocal vision lenses
$20 copay
$60 reimbursement
Lenticular vision lenses
$20 copay
$60 reimbursement
Standard progressive lenses
$85 copay
$30 reimbursement
Premium progressive lenses
20% discount off retail minus $120 allowance
plus $85 copay = member out of pocket
$30 reimbursement
UV treatment
$15 discounted fee
Not covered
Tint (solid and gradient)
$15 discounted fee
Not covered
Standard plastic scratch coating
$15 discounted fee
Not covered
Standard polycarbonate lenses – child to age 19
$40 discounted fee
Not covered
Standard polycarbonate lenses – adult
$40 discounted fee
Not covered
Standard anti-reflective coating
$45 discounted fee
Not covered
Contacts – coverage for one order of contact lenses every rolling 12 months (in lieu of eyeglass lenses per benefit period)
Conventional contact lenses
$105 plan allowance
$75 reimbursement
Disposable contact lenses
$105 plan allowance
$75 reimbursement
Medically necessary contact lenses
$0 copay
$200 reimbursement
Discounts
Available at in network locations
•15 percent off balance over the plan allowance on conventional contact lenses
•20 percent off balance over the plan allowance on frames
•Up to 40 percent off additional pairs of eyeglasses or prescription sunglasses
•15 percent discount off retail or 5 percent discount off the promotional price for LASIK
Laser vision correction or PRK from U.S. Laser Network only. Call 1-800-422-6600
•20 percent off noncovered items, including photochromic/transition and polarized lenses
•Receive significant savings after your lens benefit has been exhausted by ordering
replacement contact lenses online at www.aetnavision.com
28
Discounts may not be available in all states.
Life and disability insurance —
insurance solutions you can rely on
Protection for the future
AD&D Ultra®
Nothing is more reassuring than knowing financial resources
are available when you need them most. Our products provide
you and your dependents financial support when it counts.
And, you’ll be glad to know that with Aetna you have access to
insurance from a company with more than 150 years of
industry experience. Your financial future is in good hands.
This progressive product provides you better financial
security than typical accidental death and personal loss
plans and then some. That’s because AD&D Ultra includes
coverage for education or dependent child care expenses
upon the death of the insured.
Basic Term Life
The building block of financial security. Our life insurance
plans come with a variety of features including:
Accelerated death benefit — Also called the “living benefit,”
this benefit provides payment if you become terminally ill. This
payment can be up to 75 percent of the life insurance benefit.
Premium waiver provision — With this provision, you may
stay covered up to age 65 without premium payments if you
become permanently and totally disabled while insured due
to an illness or injury before age 60.
Disability
A serious injury or illness can keep you out of work with no
paycheck coming in. Are you prepared for that? Our disability
plans protect your income when you need it most. This
product will replace a portion of your salary to help you meet
the day-to-day expenses like your mortgage and groceries
when an illness or injury prevents you from working. Disability
coverage ensures you have some income so you can focus on
getting better, if possible.
If you need to file a disability claim, Aetna Disability makes it
easy for you, with 24-hour access to claim information online
and tools to manage your benefits.
Aetna Life Essentials
Your Aetna Life coverage includes access to Aetna Life
Essentials, a package of programs and resources available
to you and your beneficiaries at no extra cost. The Aetna
Life Essentials programs help you address health, wellness,
financial and emotional needs during your life, as well as
for those critical caring and support needs you and your
loved ones may have at the end of your life and after you’ve
passed away.
29
Get to know your Aetna prescription drug plan
You are enrolled in a Four Tier, Essential Drug
List formulary plan
Here’s what that means to you:
Think of tier as a level. Four tier means you could pay four
different amounts, depending on the drug you take.
A formulary is a list of generic and brand-name drugs that
your health plan covers. Your Essential Drug List formulary
plan covers many drugs — but it does not cover drugs on the
Formulary Exclusions List. This is a list of drugs your plan
does not cover because there are just-as-effective and less
expensive alternatives available.
Your cost depends on your prescription
With this health benefits and health insurance plan, the
amount you pay depends on the drug your doctor prescribes.
It’s either a flat fee or a percent of the prescription’s price.
Or, you will pay the full cost of any drugs on the Formulary
Exclusions List.
What you pay falls into one of these tiers or levels:
Tier One: Preferred Generics – You pay the lowest cost for
drugs in this level.
Tier Two: Preferred Brands – You pay a slightly higher cost
for drugs in this level.
Tier Three: Non-Preferred Drugs – You pay the highest
cost for drugs in this level.
Tier Four: Preferred Specialty Drugs – You pay a specific
amount for specialty drugs in this level. Specialty drugs may
be injected, infused or taken by mouth.
Formulary Exclusions List – You will pay the full cost of any
drugs on this list.
To find your exact costs
Check your Summary of Benefits & Coverage document.
This should be in your enrollment kit.
Your pharmacy benefits plan may include a program that
encourages you to choose a generic drug over a brand-name
drug, in order to help reduce what you pay. This means that
if you fill a brand-name drug when a generic is available, that
in addition to your standard copay or coinsurance, you must
also pay the difference in cost between the brand-name and
generic drug.
For a summary of your pharmacy benefits plan, including
out-of-pocket costs, visit www.aetna.com and log in to
Aetna Navigator. Or call the toll-free number on your
member ID card.
30
Save on your prescriptions
Here are some tips to pay less out of pocket for your
prescription drugs:
•Ask your doctor to consider prescribing drugs that are on
the Preferred Drug (formulary) List.
•Ask your doctor to consider prescribing generic drugs
instead of brand-name drugs.
•Check to see if your plan includes our mail-order
pharmacy service. Depending on your plan, mail order
may save you money. Read more about Aetna Rx Home
Delivery on page 23.
•Remind your doctor to check your plan to make sure you get
maximum coverage.
You may have to get plan authorization for
certain drugs
This drug coverage review encourages appropriate and
cost-effective use of prescription drugs by allowing coverage
only when certain conditions are met.
Reasons for this approval (called precertification) include:
•Compliance with dosing guidelines
•Avoiding duplicate therapies
•Helping health care providers check that a drug is being
used based on generally accepted medical criteria
The precertification program is based on current medical
findings, FDA-approved manufacturer labeling information,
and cost and manufacturer rebate arrangements.
Please keep the following in mind:
•Your doctor must contact us to request approval of coverage
for these drugs.
•If we approve the request, we will notify your doctor. The
drug will then be covered at the applicable out-of-pocket
cost under your plan. You will also be notified of approvals
where the state requires notification to members.
If the request is denied, you and your doctor will be notified.
You can still purchase the drug, but for the full price.
You may have to try one drug before another
will be covered
This drug coverage review promotes the appropriate use of
equally effective but lower-cost drugs first. Prerequisite
drugs are FDA-approved and treat the same condition as the
corresponding step-therapy drugs.
Mail order brings drugs you take every day
right to your door
Your plan includes our Aetna Rx Home Delivery mail-order
pharmacy. It fills prescriptions for maintenance medicine.
This type of medicine is used regularly, to treat conditions
like arthritis, asthma, diabetes or high cholesterol. If you need
this type of drug, you can get up to a 90-day supply, or the
maximum supply allowed by your plan, and free delivery right
to your mailbox.
You also get:
•Quick, confidential service
•Free standard shipping
•Pharmacists who check all prescriptions for accuracy and
can answer questions any time
Over-the-counter drugs may be an option
Many health conditions can be treated safely with drugs you
can get without a prescription. We call these drugs “over the
counter” because you can buy them at your local stores.
You don’t have to go to a pharmacy.
These drugs have been approved by the FDA as safe and
effective, and they often have the same active ingredients as
an original prescription version. Always talk to your doctor
before taking over-the-counter drugs.
Your plan does not cover prescription drugs if a similar drug
is available over the counter. This includes drugs like Claritin®
and Prilosec® 20 mg. Please ask your doctor what will work
best for you.
Use our specialty pharmacy for drugs that
require special handling
Aetna Specialty Pharmacy is our in-house specialty pharmacy
for prescription specialty medicine. These types of drugs may
be injected, infused or taken by mouth. Specialty medicine
often needs special storage and handling. It must be delivered
quickly. And a nurse or pharmacist should monitor you during
your treatment. Use Aetna Specialty Pharmacy to get this
medicine sent right to your mailbox. You also get:
•Free delivery that is reliable, secure and sent anywhere
you choose
•Extra help when you need it — like injection training and
side effect monitoring
•Proactive outreach to confirm your refills
•Free standard supplies
•Nurses and pharmacists who can help you 24 hours a day,
every day
Claritin is a registered trademark of Schering-Plough HealthCare Products Inc.
Prilosec is a registered trademark of AstraZeneca LLP.
31
Limitations and exclusions
These plans do not cover all health care expenses and
include exclusions and limitations. Refer to your plan
documents to determine which health care services are
covered and to what extent.
Medical
The following is a partial list of services and supplies that are
generally not covered. However, the plan documents may
contain exceptions to this list based on state mandates or the
plan design purchased.
Aetna HMO and HNOption
•All medical and hospital services not specifically covered
or that are limited or excluded by the plan documents,
including costs of services before coverage begins and
after coverage terminates
•Blood and blood by-products, except as administered on an
inpatient or emergency care basis
•Cosmetic surgery
•Custodial care
•Dental care and dental X-rays
•Donor egg retrieval
•Experimental and investigational procedures (except for
coverage for medically necessary routine patient care costs
for members participating in a cancer clinical trial)
•Hearing aids, unless specifically listed as covered in the plan
documents
•Home births
•Implantable drugs and certain injectable drugs, including
injectable infertility drugs
•Infertility services, including artificial insemination and
advanced reproductive technologies, such as IVF, ZIFT, GIFT,
ICSI and other related services, unless specifically listed as
covered in the plan documents
•Long-term rehabilitation
•Nonmedically necessary services or supplies
•Orthotics, except diabetic orthotics
•Outpatient prescription drugs (except for treatment of
diabetes), unless covered by a prescription plan rider, and
over-the-counter medications (except as provided in a
hospital) and supplies
•Radial keratotomy or related procedures
•Reversal of sterilization
•Services for the treatment of sexual dysfunction or
inadequacies, including therapy, supplies or counseling
or prescription drugs
•Special duty nursing
•Therapy or rehabilitation, other than those listed as covered
•Treatment of behavioral disorders
32
•Weight-control services, including surgical procedures,
medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and other
medications; food or food supplements, exercise programs,
exercise or other equipment; and other services and supplies
that are primarily intended to control weight or treat obesity,
including morbid obesity, or for the purpose of weight
reduction, regardless of the existence of comorbid conditions,
unless specifically listed as covered in the plan documents
Aetna PPO and Indemnity
•All medical or hospital services that are not specifically
covered or that are limited or excluded in the plan
documents
•Charges related to any eye surgery, mainly to correct
refractive errors
•Cosmetic surgery, including breast reduction
•Custodial care
•Dental care and X-rays
•Donor egg retrieval
•Experimental and investigational procedures
•Hearing aids, unless specifically listed as covered in the plan
documents
•Infertility services, including, but not limited to, artificial
insemination and advanced reproductive technologies, such
as IVF, ZIFT, GIFT, ICSI and other related services, unless
specifically listed as covered in the plan documents
•Nonmedically necessary services or supplies
•Orthotics, as specified in the plan
•Over-the-counter medications and supplies
•Reversal of sterilization
•Services for the treatment of sexual dysfunction or
inadequacies, including therapy, supplies and counseling
•Special-duty nursing
•Weight-control services, including surgical procedures,
medical treatments, weight control/loss programs, dietary
regimens and supplements, appetite suppressants and
other medications; food or food supplements, exercise
programs, exercise or other equipment; and other services
and supplies that are primarily intended to control weight
or treat obesity, including morbid obesity, or for the purpose
of weight reduction, regardless of the existence of comorbid
conditions, unless specifically listed as covered in the
plan documents
Dental, AD&D Ultra and disability
Employee and dependent life insurance
Dental, AD&D Ultra and disability plans include limitations,
exclusions and charges or services that these plans do not
cover. For a complete listing of all limitations and exclusions
or charges and services that are not covered, please refer to
your Aetna group plan documents. Limitations, exclusions
and charges or services may vary by state or group size.
The plan may not pay a benefit for deaths caused by suicide,
while sane or insane, or from an intentionally self-inflicted
injury, within two years from the effective date of the
person’s coverage. If death occurs after two years of the
effective date but within two years of the date that any
increase in coverage becomes effective, no death benefit
will be payable for any such increased amount.
Dental
Listed below are some of the charges and services for which
these dental plans do not provide coverage. For a complete
list of exclusions and limitations, refer to the plan documents.
•Dental services or supplies that are primarily used to alter,
improve or enhance appearance
•Experimental services, supplies or procedures
•Treatment of any jaw joint disorder, such as
temporomandibular joint disorder
•Replacement of lost, missing or stolen appliances and
certain damaged appliances
•Those services that Aetna defines as not necessary for the
diagnosis, care or treatment of a condition involved
•Specific service limitations:
--DMO plans: Oral exams (four per year)*
--PPO plans: Oral exams (two routine and two
problem-focused per year)
--All plans:
--Bitewing X-rays (one set per year)*
--Complete series X-rays (one set every three years)*
--Cleanings (two per year)*
--Fluoride treatments (one per year; children under 16)
--Sealants (one treatment per tooth, every three years
on permanent molars; children under 16)*
--Scaling and root planing (four quadrants every
two years)
--Osseous surgery (one per quadrant every three years)
•All other limitations and exclusions in the plan documents
*The frequent calendar-year limits for these services will not apply to the DMO plans if they are needed more frequently due to
medical necessity.
33
AD&D Ultra
Disability
Not all events that may be ruled accidental are covered
by this plan. No benefits are payable for a loss caused or
contributed to by:
Disability coverage also does not cover any disability that:
•Air or space travel, unless a person is a passenger, with
no duties at all, on an aircraft being used only to carry
passengers (with or without cargo)
•Bodily or mental infirmity
•Commission of or attempting to commit a criminal act
•Illness, ptomaine or bacterial infection*
•Inhalation of poisonous gases
•Intended or accidental contact with nuclear or atomic
energy by explosion and/or release
•Ligature strangulation resulting from autoerotic
asphyxiation
•Intentionally self-inflicted injury
•Medical or surgical treatment*
•Third-degree burns resulting from sunburn
•Use of alcohol
•Use of drugs, except as prescribed by a physician
•Use of intoxicants
•Use of alcohol or intoxicants or drugs while operating any
form of a motor vehicle whether or not registered for land,
air or water use. A motor vehicle accident will be deemed
to be caused by the use of alcohol, intoxicants or drugs
if it is determined that at the time of the accident the
member was:
-Operating the motor vehicle while under the influence of
alcohol at a level that meets or exceeds the level at which
intoxication would be presumed under the laws of the
state where the accident occurred. If the accident occurs
outside of the United States, intoxication will be presumed
if the person’s blood alcohol level meets or exceeds .08
grams per deciliter; or
-Operating the motor vehicle while under the influence of
an intoxicant or illegal drug; or
-Operating the motor vehicle while under the influence of a
prescription drug in excess of the amount prescribed by
the physician; or
-Operating the motor vehicle while under the influence
of an over-the-counter medication taken in an amount
above the dosage instructions.
•Suicide or attempted suicide (while sane or insane)
•War or any act of war (declared or not declared)
34
•Is due to an occupational illness or occupational injury
except in the case of sole proprietors or partners who
cannot be covered by workers’ compensation
•Is due to insurrection, rebellion, or taking part in a riot
or civil commotion
•Is due to intentionally self-inflicted injury
•Is due to war or any act of war (declared or not declared)
•Results from the commission of, or attempting to commit
a criminal act
•Results from an accident caused by operating the vehicle
while the member is under the influence of alcohol. A motor
vehicle accident will be deemed to be caused by the use of
alcohol if it is determined that at the time of the accident
the member was operating the motor vehicle while under
the influence of alcohol at a level that meets or exceeds the
level at which intoxication would be presumed under the
laws of the state where the accident occurred. If the
accident occurs outside of the United States, intoxication
will be presumed if the person’s blood alcohol level meets or
exceeds .08 grams per deciliter
No benefits are payable on any day during a period of
disability that you are confined in a penal or correctional
institution for conviction of a felony or other public offense.
*These do not apply if the loss is caused by:
- An infection that results directly from the injury.
- Surgery needed because of the injury.
The injury must not be one that is excluded by the terms of this section.
Find a doctor or specialist
Start your search at www.aetna.com (or, if you are already
a member, log in to Aetna Navigator). Click on Find a Doctor.
Use the simple online instructions to perform a general
search. Also, you may search for a particular physician by
name, specialty or other options.
Savings Plus
Look for the symbol.
How to find your Arizona plan
When performing a search in DocFind, you will be asked to
select a plan name. Some of the names of our Arizona plans
appear by their network names. Here is a quick reference to
identify your plan:
Aetna Whole Health
Look for the symbol.
Medical plan name as it
appears in DocFind
Common plan
names
HMO
HMO
Open Choice PPO
PPO
Aetna Health Network Option
(Open Access)
HNO Option
Savings Plus of Arizona
Savings Plus
(AZ) Aetna Whole Health Plan
Arizona Care Network
Banner Health Network
Arizona Care Network
and Banner Health
®
35
How to complete
Please be sure to complete your enrollment form thoroughly.
NOTE: Before submitting this completed form to your employer, you may wish to protect the confidentiality of your health
information by taping or stapling the form so that health information is not visible.
The sections noted below are frequently overlooked.
1. Date of hire.
2. Select the medical plan(s) offered by your employer.
If dental plans are offered, select your dental plan next.
3. Insert your Social Security number here.
4. Enter your doctor’s (and dentists if enrolling in a
DMO plan) ID number if enrolling in a HMO plan.
5. Sign here if you are waiving coverage for yourself
or any dependents.
6. Sign and date here to complete the form.
Arizona Group Business Employee
Enrollment/Change Form (2 - 50 Eligible Employees)
INSTRUCTIONS: You, the employee, must complete this enrollment form in full or it will be returned to you
resulting in a delay in processing. You are solely responsible for its accuracy and completeness. If waiving
coverage, please complete Sections C and H.
Company Name
Effective Date
1
2
2
Date of Hire
Change of Coverage
Add Spouse/Domestic
Partner
Add Dependent Child
Name Change
Other
New Hire
Rehire/Reinstatement
New Group Enrollment
Late Enrollment
Other
Plan No.
1. Medical - Check one.
HMO - Plan Option:
HNO - Plan Option:
PPO - Plan Option:
Indemnity - Plan Option:
Class Code
Savings Plus - Plan Option:
Aetna Whole Health/Arizona Care - Plan Option:
Aetna Whole Health/Banner - Plan Option:
Suffix
Account
Class Code
Plan No.
2. Dental: Check one (if applicable).
Standard Plans:
Aetna Dental® Plan – Plan Option:
Voluntary Plans:
Aetna Dental® Plan – Plan Option:
For FOC, choose:
For FOC, choose:
Before today, were you covered under this employer’s dental plan?
E. Dependent Information
Control/Group No.
Suffix
3. Life and Disability
Basic Life/AD&D Ultra®
Account
Name
Yes
DMO® or
DMO® or
Class Code
Life & Disability Packaged Plan
Beneficiary Social Security Number
Address
Beneficiary Address (Number,
Street, Apt. No., City, State, ZIP Code)
PPO
PPO
No
Plan No.
Optional Dependent Life
Full Beneficiary Name (First, Middle, Last)
List any dependent in Section D living at another address.
Member Aetna ID Number (if available)
COBRA for:
Employee
Termination
Employee
Dependent
Remove Spouse/
Length of Continuation:
Domestic Partner
18
36
Other
Remove Dependent
Original Qualifying Event Date
Child
Cancel Coverage
Qualifying Event
A. Coverage Selection – Please print clearly, using black ink.
Control/Group No.
Suffix
Account
Control/Group No.
Group Number
Birthdate (MM/DD/YYYY)
/
Telephone Number
( )
-
/
Relationship to Employee
B. Life Health Questionnaire for Employees who are requesting Basic Life benefits greater than the Guaranteed Issue Level) -- Please
complete the Uniform Employee Health Status Questionnaire, which can be found at www.id.state.az.us/consumerbusiness.html#health.
For Life Only: If age 19 and over and a full-time student, provide the following:
C. Employee Information – Must be completed by the employee.
Child Name
School Name
Expected Graduation Date Number of Credit Hours
Social Security Number
Last Name, First Name, M.I.
Job Title
Home Telephone
3
Home Address
Apt. No.
City, State
ZIP Code
F. Coordination of Benefits
Work Address
City, State
ZIP Code
Work Telephone
Will you have other health insurance at the same time as this coverage?
Yes
No
D. Individuals Covered - List individuals for whom you are enrolling or adding/changing/removing coverage. Insert additional sheets if
Salary
(Complete
only
if
Primary
Language
Number
of
Check
One:
Number of
Name of Person
Carrier Name
Name of Person
Carrier Name
necessary.
Hourly
enrolling for Life or
Spoken (Optional)
Hours Worked
Dependents
Full-Time
Part-Time
1099
Employee
Name (Last, First, M.I.) Monthly
Sex
Social Security Number
Birthdate
(A)dd
Disability)
Per Week
Seasonal
Retiree
COBRA Excluding Self
(M/F)
(MM/DD/YYYY)
1 (C)hange
Weekly
$
Union
Temporary
(R)emove
Coverage Election
Other Dental Prior Dental Primary Office ID # Current Dental Office ID # Current
Status
Single
Conditions of
EnrollmentDivorced
Coverage
Coverage
(If applicable)
Patient (If applicable)
Patient
Medical
Widowed listed on
Dental
On behalf of Married
myself and the dependents
the reverse side, IYes
agree to or with
the following:
Yes
Yes
Yes
G. Medicare Information
Legally
Separated
1. I acknowledge that by enrolling in the following
plans, coverage is provided by the following entities (collectively referred to as “Aetna”):
Life/Dis
Renal
● Aetna HMO and Aetna
HNO plans]:
Aetna Health Inc., Aetna Health Insurance CompanyEnd-Stage
and/or1Aetna
Life Insurance Company.
GR-68900-9
(1-14)
AZ R-POD A
Medicare
Medicare
Medicare
Sex Disease
Social
Security
Effective
First,
M.I.)
Spouse
● (A)dd
Aetna PPO plans,Name
Aetna(Last,
CDHP-HSA
plans, Aetna
Savings Domestic
Plus plansPartner
and Aetna Whole
Health
plans:
AetnaNumber
Life InsuranceBirthdate
Company.
(MM/DD/YYYY)
2 Part
Date
Name of Person
Over Age
65 DMO®)Disability
A AccidentalPart
B & Personal Loss,
Part Ddisability, dental
and all other(M/F)
coverages:
Aetna Life Insurance Company.
DMO®
● (C)hange
Life,
Death
(except
(R)emove
Yes dental
Nocoverage
Yesis provided
No by Aetna
Yes HealthNoInc.
Yes
No
Yes
No
Coverage
Election formOther
Dental Prior
DentalandPrimary
Office
ID coverage
# Currentunless
Dental
ID # the Current
Status
2. I understand
and last
agree
that my employer’s
enrollment
will determine
coverage
that there
is no
andOffice
until both
eligible
Different
name
Coverage
Coverage
applicable)
Patient
(If applicable)
Medical
Yes
No enrollment
Yes form and
No employer
Yes applications
No
Yes
No
Yesapproved
No(Ifby
employee
have
been accepted
and
Aetna. Even if this
enrollment
form is approved,Patient
any
Dental
Yes and the policy
Yes or my coverage under the policy
Yes being rescinded or
Yes
misstatements or omissions may result in future
claims being denied
Life
H. Declination/Waiver of Coverage – Toreevaluated,
be completed
if
medical
and/or
dental
coverage
is
declined
or
refused
by
an
eligible
employee
as of the effective date, for eligibility and rating purposes.
and/or
their
family
members.I understand that the effective date of insurance for myself or for any of my dependents is subject to my being
For
life
andeligible
disability
coverages:
Sex
Social
Security
Number
(A)dd
Name (Last, First, M.I.)
Child
Stepchild
Other
at work on
date and
that the effective date of insurance for any of my dependents is also subject(M/F)
to the dependent health condition
Reason
forthat
declining
coverage
3 actively
(C)hange
Employee:
Medical
Dental
requirements
of the benefit plan.Partner
Further,
I understand
subject
to evidence
of good health or medical information will not
(R)emove Spousal/Domestic
group
coverage that any insurance
Insurance
through
another job
Life
Disability
become
effective
until
Aetna
gives
its
written
consent.
For
Dependent
Life:
dependents
are
eligible
from
14
days
of age
up to
their Coverage
19th birthday or
Coverage
Prior
Dental
Birthdate
Status
group
coverage
TRICARE
Military Election
coverage Other Dental
rd birthday,
Different
last name
up to their 23Parental
if a full-time
student.
Medical
Dental
Spouse/
Coverage
Medical
(MM/DD/YYYY)
Yes
Lives at another address
3. I understand Medicare
and agree that this Enrollment/Change
Form may be AHCCCS
transmitted to Dental
Aetna or its agent by myYes
employer or its agent. I authorize any
Domestic
Life
Full-timehospital
Student–Life
physician, other
healthcare professional,
or anyOnly
other healthcare
organization
Partner:
Medicaid
Indian Health
Services
Life (“Providers”), including pharmacies or pharmacy database
benefit managers
to give
to AetnaIncapacitated
or its agent information concerning
the medical
history,
Retiree
coverage
Individual
coverage
- Onprescription
Exchange utilization history, services or treatment
Child(ren):
Medical
Dental
Primary
OfficetoIDanyone
#
Current Patient Form,Dental
Office
ID #involving mental
Current
Patient
provided
listed on this Enrollment/Change
including
those
health
and substance
abuse. I furtherYes
authorizeNoAetna
Incapacitated
Another group
provided
by my
employerto(Ifaffiliates,
Individual
coverage
Off Exchange
(If applicable)
applicable)
Life
to use such information
andplan
to disclose
such
information
Providers,
payors,– other
insurers,
Yes
Yes third party administrators, vendors,
COBRA
coverage authorities with jurisdiction when necessary
Do not want
consultants and
governmental
for my care or treatment, payment for services, the operation of my
health plan, or to conduct related activities. I have discussed the terms
partner and competent adult
Otherof this authorization with my spouse/domestic
Sex
Social Security Number
(A)dd
Name
(Last, First,
Stepchild
dependents, and I have
obtained
their M.I.)
consent toChild
those terms.
I understandOther
that this authorization is provided under state law, and that it is not an
(M/F)
4 to(C)hange
I acknowledge I have been given the right
apply for thiswithin
coverage;
however,
amfederal
electingHealth
not toInsurance
enroll. ByPortability
declining and
this group
coverageAct.
I
“authorization”
the meaning
of Ithe
Accountability
(R)emove
acknowledge that I and/or my dependents may
have to wait until the plan's next anniversary date to be enrolled for group coverage.
This authorization is Status
valid for term of the coverage and so long thereafter as
allowedElection
by law. I understand
that I am entitled,
as is any
authorized
Coverage
Other Dental
Prior Dental
Coverage
Birthdate
Different
last name
Please sign here ONLY if you are declining
coveragethat
for yourself
or dependent(s).
(Month/Day/Year)
representative
I may designate,
to receive
a copy of this authorization uponDate
request
and thatCoverage
a photocopy is as valid as the original.
Medical
(MM/DD/YYYY)
Yes
Livesofatcollecting
another address
4. Authorizations signed for the purpose
information in connection withDental
this enrollment form for Yes
an insurance policy, a policy reinstatement
Employee Signature X
Only for thirty (30) monthsLife
or a request for changes in policyFull-time
benefits Student–Life
shall remain valid
from the date signed. Authorization signed for the purpose of
Incapacitated
collecting information in connection
with a claim for benefits shall remain valid for the term of this coverage or for so long as allowed by law. The
Primary
Office ID as
# well as other personalCurrent
Patientinformation,
Dental
Office ID # collected by
Current
Patient institution
Incapacitated
Yes
information,
or privileged
subsequently
the insurance
or agent may, in
certain No
(If applicable)
(If applicable)
Yes authorization.
Yesexists with respect to all personal information
circumstances, be disclosed to third parties without
A right of access and correction
collected. Further disclosures required by Arizona law will be furnished to the policyholder upon request. Personal information may be collected
from
persons other than the individual or individuals proposed for coverage.
Sex
Social Security Number
(A)dd
Name (Last, First, M.I.)
Child
Stepchild
Other
5.5 The
plan documents will determine the rights and responsibilities of member(s) and will govern in the event they
(M/F)conflict with any benefits
(C)hange
comparison,
(R)emove summary or other description of the plan.
®, all participating
and vendors arePrior
independent
contractors
6. I understand and agree
that, with the exception of Aetna Rx Home Delivery
Coverage
Election providers
Other Dental
Dental Coverage
Birthdate
Status
Different
last name
and are neither agents nor employees
of Aetna.
Aetna Rx Home Delivery, LLC, is
a subsidiary ofCoverage
Aetna Inc. The availability of anyYes
particular
Medical
(MM/DD/YYYY)
Lives
at another
address
provider cannot be guaranteed and
provider
network
composition is subject to change.
Dental Notice of the change
Yes shall be provided in accordance with
Full-time
Student–Life
Only
applicable state law.
Life
7. I understand and agree that, with Incapacitated
certain exceptions described in the plan documents, HMO and DMO® plans only provide coverage for referred
Primary
Officeand
ID #that, in order to be covered,
Current
Patientmust beDental
Officeeither
ID # by a participating
Currentprimary
Patient care physician,
Incapacitated
Yes
benefits,
services
performed
primary care
dentist,No
or by
(If applicable)
(If
applicable)
Yes
Yes from a participating primary care physician.
the participating specialist, hospital,3 pharmacy,
dentist, or other provider as authorized by a referral
GR-68900-9 (1-14)
AZ
4
5
6
36
4
I represent
in this
true and complete.
read and agree to the ConditionsSex
of Enrollment
this Arizona
Group
SocialonSecurity
Number
(A)ddthat all information
Namesupplied
(Last, First,
M.I.)form isChild
StepchildI haveOther
Business
Employee Enrollment/Change Form. I understand that, in the event I fail to sign this form within 31 days(M/F)
after the above transaction request or
6 (C)hange
for any(R)emove
reason Aetna does not receive notice of the above transaction request within a reasonable time following the event, my and my dependents’
eligibility may be affected.Status
I am employed by the employer shown on Page 1 at
the regular
place of business.
Coverage
Election
Other Dental
Prior Dental Coverage
Birthdate
Different last name
Employee
E-mail Address
(optional)
Coverage
Employee Signature
Date (Month/Day/Year)
Medical
(MM/DD/YYYY)
Yes
Lives at another address
Dental
Yes
X
Full-time Student–Life Only
Life
Incapacitated
Primary Office ID #
Current Patient
Dental Office ID #
Current Patient
Incapacitated
Yes
No
(If applicable)
(If applicable)
Yes
Yes
GR-68900-9 (1-14)
2
AZ
Your member ID card
After you enroll, you will receive ID cards that look like this. If
you need care before your ID card arrives in the mail, you may
log in to Aetna Navigator and print a temporary ID card. Make
sure to present your Aetna ID card when receiving care from
participating providers or when accessing emergency care.
Your ID card shows key information:
1. Plan in which you are enrolled.
2. Additional information, including precertification number
for mental health and substance abuse services.
3. Call this number to speak with a Member Services
representative.
Printed on biodegradable card stock
(bio PVC). One card for up to five family
members. One card combining medical,
dental and Rx information.
1
2
3
1
2
3
Specialized medical product:
Arizona Care Network
Banner Health Network
37
Contact information
Member services
Medical
Pharmacy
For benefits questions or claims inquiries for Aetna HMO Plan
including Aetna Whole Health – Arizona Care Network and
Aetna Whole Health – Banner Health Network HMO plans
1-888-702-3862
1-800-AETNA RX or 1-800-238-6279
Claims address:
Aetna
P.O. Box 14079
Lexington, KY 40512
For benefits questions or claims inquiries for Aetna PPO Plan,
Aetna Indemnity Plan, Savings Plus, HNO, Banner Health
Network – Aetna Whole Health, Arizona Care Network –
Aetna Whole Health
1-888-802-3862
Claims address:
Aetna
P.O. Box 981204
El Paso, TX 79998-1204
Dental
1-877-238-6200
Claims address:
Aetna
P.O. Box 14094
Lexington, KY 40512-4094
Life
1-800-523-5065
Claims address:
Aetna Life Insurance
P.O. Box 14548
Lexington, KY 40512-4548
Disability
1-866-326-1380
Claims address:
Aetna Disability
P.O. Box 14560
Lexington, KY 40512-4560
38
Prompt 2 (Member or calling on
behalf of a member)
Claims address:
Aetna Pharmacy Management
P.O. Box 14024
Lexington, KY 40512-4024
Mail-order drugs
1-866-612-3862
Ordering address:
Aetna Rx Home Delivery
P.O. Box 417019
Kansas City, MO 64179-9892
Other programs
Aetna Vision Discount Program
1-800-793-8616
Call for closest eye care provider
Informed Health® Line
1-800-556-1555
24-hour nurse help line
Aetna Behavioral Health
1-800-424-5702
Visit our secure member website online
Your secure Aetna Navigator member website is available
24 hours a day, 7 days a week. Use it to perform common
transactions involving your Aetna medical, dental,
prescription drug or flexible spending account (FSA) plans.
You can send a secure e-mail to Aetna Member Services,
access claims, see who’s covered, and view general health
information and decision-support tools. Log in to the Aetna
Navigator website at www.aetna.com.
Review the material in this brochure and speak with
your employer or human resources representative
about the choices available to you.
We look forward to welcoming you and your family
as our newest members.
If you need this material translated into another language, please call Member Services at 1-888-98-AETNA (1-888-982-3862).
Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-888-98-AETNA (1-888-982-3862).
This material is for information only and is neither an offer or invitation to contract. The models depicted are not Aetna members.
An application must be completed to obtain coverage. Rates and benefits vary by location. Providers are independent contractors
and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to
health services. Health and life insurance plans contain exclusions and limitations.
Discount offers provide access to discounted services and are NOT insured benefits. Discount offers are rate-access offers and may
be in addition to any plan benefits. Check any insurance benefits you have before using these discount offers, as those benefits may
result in lower costs to you than using these discounts. Discount offers are not guaranteed and may be discontinued at any time.
Aetna makes no payment to the discount vendor. The member is responsible for the full cost of the discounted services. Aetna may
receive a percentage of the fee you pay to the discount vendor. Health information programs provide general health information
and are not a substitute for diagnosis or treatment by a physician or other health care professional.
Aetna does not endorse any vendor, product or service associated with these discount offers. Vendors are independent of Aetna,
not agents or employees thereof. Programs, products and services may not be available at all times. Certain offers may not be
available in some states. Products may be subject to a warranty from the manufacturer. Aetna makes no representations or
warranties, and disclaims all product warranties. The discount offers have no liability for providing or guaranteeing service and
assumes no liability for the quality of service rendered. Aetna may receive a percentage of the fee paid to a discount vendor. While
this material is believed to be accurate as of the production date, it is subject to change.
Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates
do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home
Delivery, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy providing prescription services by mail. This pharmacy is a
for-profit entity. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed
pharmacy that operates through specialty pharmacy prescription fulfillment. Information is believed to be accurate as of the
production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com.
www.aetna.com
©2014 Aetna Inc.
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