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Health Insurance

Aetna 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

Resources 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

Medical and Prescription Plans

Medical Plan Benefits

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.

Dental Plan

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

Dependent 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:

Up to age 19, or up to age 25 with student verification

Unmarried

Financially dependent upon the employee for support

Student Verification Requirements

The student verification process will start once a claim is submitted to Aetna. Once a member turns 19, Aetna will pend payment on all claims for that member until student verification has been provided. Claims will be pended for 45 days. If dependent verification is not provided within the 45-day time period the claim will be denied and no benefits will be paid. More on student verification requirements » (PDF)

Newborns

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.

Aetna Navigator Features

How 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

Download a PDF version of this information

DocFind 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)
Enter City, County or Zip code, depending upon your search preference Select a Type of Provider Select a Plan – The category is Aetna Standard Plans. Then, select Open Choice PPO for the type of plan. Select Search Criteria – you can narrow your results further or choose to view results for all providers.		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 Place your curser over the "Health Coverage Info" option at the top & choose "Drugs & Prescriptions" from the list of options. Click on "Preferred Drug List (Formulary)" and then follow the "Preferred Drug Guides" links to get to the Search box. 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		Dental Member Services P.O. Box 14094 Lexington, KY 40512-4094 1-877-238-6200 www.aetnadental.com		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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