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Health Insurance

AetnaAetna Health Insurance

ACE, APA, Exempt, Food Service, Maintenance, Non-Represented, and TOTEM employees are covered by Aetna's Open Choice PPO Plan (Group #658742). For more information contact Member Services or visit Aetna Navigator online.

 

These employees should visit the following pages for more information:

AEA employees »
Teachers

Local 71 employees »
Custodians

Teamsters 959 employees »
Bus drivers & attendants

 

KeyResources from Aetna

Aetna Claim & EOB Forms
» Medical Claim Form
» Dental Claim Form
» Prescription Drug Claim Form
» Prescription Home Delivery
» Sample Explanation of Benefits (EOB) form
Information about Aetna and the
Open Choice Plan
» DocFind Provider Directory
» Informed Health Line
» Open Choice Plan
» Simple Steps to a Healthier Life

 

KeyMedical, Dental and Prescription Plans

Medical Plan Benefits Shim Prescription Plan Benefits
» $600 individual/$1,800 family deductible
» pays 80% of the next $20,000 of covered charges
» once your 20% out of pocket expenses reaches $4,000, the plan will pay 100% of covered charges
» $30 general office visit co-pay
 
Type of Drug Retail Mail Order
Generic Drugs » $15 co-pay for each 30-day supply (or cost of prescription if less than co-pay) » $30 co-pay for each 90-day supply (or cost of prescription if less than co-pay)
Brand Name Formulary Drugs » 20% coinsurance (up to $120 cap) » 20% coinsurance (up to $80 cap)
Brand Name Non-Formulary Drugs » 20% coinsurance (up to $240 cap) » 20% coinsurance (up to $160 cap)

Mandatory Generic (MG) - If the member requests a brand prescription when a generic prescription is available, the member will be responsible for paying the applicable copay, plus the difference between the generic price and the brand price. The physician may state "dispensed as written" for the tiers above to apply.

 

Aetna Specialty Pharmacy

Learn more about this program for employees with chronic conditions:

Dental Plan Benefits  
The benefits below are based on plan allowance for the service provided. Pre-authorization of major treatments is not required, but is recommended.
» 100% of diagnostic and preventative care within UCR (Usual Customary Rates)
» 80% of basic care
» 50% of major care
» $3,000 maximum per enrollee per calendar year (January-December)
» $25 annual deductible on basic and major care
 

 

KeyDependent Eligibility Verification

Your health benefits are an important part of your life and we are continually working to provide good service while keeping costs as low as possible. To do that we need to ensure that the district health plan pays claims only for those dependents who are eligible for benefits. Click here for information about who is eligible and what you need to do to verify eligibility » (PDF)

Definition of Dependent Child Eligibility
All of the following criteria must be met:

• Coverage will be offered for children until  age 26.

• Children must be enrolled according to the terms of the Plan.

• Coverage of enrolled children will cease at age 26 unless applicable law requires us to offer coverage for a longer period of time.

• No coverage will be provided for adult children who are eligible to enroll in an eligible employer-sponsored health plan.

KeyNewborns

Please come to the Benefits Department to enroll your newborn within 31 days of birth with a state or hospital birth certificate. Failure to enroll your child within this period will result in loss of medical coverage. You will need to enroll your dependent during the next open enrollment period for coverage to begin the following fiscal year.

 

Aetna Navigator

Eligible employees under the district's health insurance should register on the Aetna Navigator. Below are some great features available on their Web site and instructions on how to access them.

KeyAetna Navigator Features

Shim

KeyHow to…

  • Use DocFind to locate a physician, specialist or medical facility

  • View who is covered on your plan

  • Print a temporary medical ID card or order a new card if your card has been lost or stolen

  • View Explanation of Benefits for Claim Status

  • E-mail Customer Service in a secure environment with questions about benefits or claims

  • Access the Prescription Drug Formulary

  • Print forms to begin the Pharmacy Mail Order process

  • Access Aetna InteliHealth featuring Harvard Medical School's Consumer Health Information

 

Register for Aetna Navigator

  • Go to www.aetna.com
  • Click on Member Log In +
  • Enter User Name & Password and click on Log In -> then click OK
  • Click on “Go” under “First-Time User I’m ready to register”
  • Make a selection by clicking on subscriber and press Next
  • To finalize the registration process complete all required fields and click on Next
  • Please keep your User ID and password you created in a secured location
  • Call Aetna at (800) 225-3375 if you have problems registering

Print a temporary ID card (after you log into Aetna Navigator)

  • Look under Related Shortcuts left side of screen & click on ID Card
  • Click on Medical Temporary Identification
  • Next select the covered member you wish to view, click “Continue”
  • Use the Internet browser to print the “Temporary Member Identification” image
Up arrowDownload a PDF version of this informationUp arrow

KeyDocFind Provider Directory & Medication Formulary Guides

The Aetna web site is also a great way to search the "DocFind Provider Directory" and "Medication Formulary Guides," which are now available.

To access "DocFind" use the "Find a Doctor" link under Shortcuts.  Follow the steps on the next screens:   To access Prescription Drug Search
(Pharmacy plan type is Three Tier Open Formulary – use this to search)
  1. Enter City, County or Zip code, depending upon your search preference

  2. Select a Type of Provider

  3. Select a Plan – The category is Aetna Standard Plans.  Then, select Open Choice PPO for the type of plan.

  4. Select Search Criteria – you can narrow your results further or choose to view results for all providers.

Shim
  1. On the Shortcuts menus follow the "Look up a Drug link or the "Is Your Drug Covered? (Preferred Drug List) link.
    OR
    From the www.aetna.com home page, follow the "Members: Public Information" link

  2. Place your curser over the "Health Coverage Info" option at the top & choose "Drugs & Prescriptions" from the list of options. 

  3. Click on "Preferred Drug List (Formulary)" and then follow the "Preferred Drug Guides" links to get to the Search box.

  4. To search, make sure you are under Non-Medicare Plans, then select Three Tier Open Formulary in the drop-down box.

Contacting Aetna

Please contact the appropriate Aetna Service Centers with any questions:

Medical Member Services
P.O. Box 14089
Lexington, KY 40512-4089
1-877-204-9186
www.aetna.com

Shim Dental Member Services
P.O. Box 14094
Lexington, KY 40512-4094
1-877-238-6200
www.aetnadental.com
Shim Aetna Pharmacy
Attn: Claim Processing
P.O. Box 14024
Lexington, KY 40512-4024
1-800-238-6279
www.aetnapharmacy.com
This is an AETNA Standard "Open Choice PPO Plan" and the Group Number is 658742

 

 

 

Please note

The plan booklet files provided on this site are solely to facilitate the Group’s review of available benefits. The electronic text is in a “Read Only” format. Alterations, additions, or deletions to the text are prohibited. Any unauthorized review, use disclosure, or distribution of this text is prohibited.

Efforts have been made to ensure this Web site contains accurate information. In the event of a discrepancy between the electronic text and the hard copy plan document, the hard copy plan document will prevail.

PDF Forms

Forms on this site are designed to be filled out by hand or on your computer, printed out, and mailed to the appropriate office. Due to the limitations of the free Adobe Acrobat Reader software you will be unable to save your changes unless you have a full version of Adobe Acrobat.

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2012 Open enrollment
May 7 - June 1, 2012

It's time to take care of business
Time to take care of business

 


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