AETNA ADVANTAGE PLANS FOR INDIVIDUALS,
FAMILIES AND THE SELF-EMPLOYED
NEW PROVISIONS EFFECTIVE SEPTEMBER 23, 2010
This information is an addendum to the printed materials you received.
©2010 Aetna Inc.
13.03.536.1 (7/10)
The federal health care
reform legislation, known
as the Patient Protection
and Affordable Care Act,
was signed into law
on March 23, 2010 by
President Obama.
The following health care
reform changes are effective
on September 23, 2010:
• Allow dependent coverage up
to age 26
• Remove lifetime benefi t limits –
based on dollar amounts
• Take away cost-sharing obligations
for preventive services (In network)
• Eliminate pre-existing condition
exclusions for dependent children
(under 19 years of age)
Please note that some previously
printed materials do not refl ect these
changes. However, the new provisions
are in effect for plans with an effective
date on or after September 23, 2010,
and your Aetna Advantage Plan does
comply with the new federal health
care reform legislation.
If you have any questions, please talk to
your broker or call 1-800-MY-HEALTH.
Please note that in addition to health care reform changes, coverage for children only may
no longer be available in your state. Also, all plans described in the printed material you
received may not currently be available in your state.
Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten by Aetna
Life Insurance Company (Aetna) directly and/or through an out-of-state blanket trust or Aetna
Health Inc. In some states, individuals may qualify as a business group of one and may be eligible
for guaranteed issue, small group health plans. These plans are medically underwritten and you may be
declined coverage in accordance with your health condition.
Aetna Advantage Plans for Individuals, Families and the Self-Employed are underwritten
by Aetna Life Insurance Company (Aetna) directly and/or through an out-of-state
blanket trust. In some states, individuals may qualify as a business group of one and
may be eligible for guaranteed issue, small group health plans. These plans are medically
underwritten and you may be declined coverage in accordance with your health condition.
Kentucky Aetna Advantage Plan Options
©2009 Aetna Inc.
KY PHC 1250 (9/09)
Preventive And Hospital Care 1250
MEMBER BENEFITS In-Network Out-of-Network
+
Deductible
Individual
Family
$1,250
$2,500
$2,500
$5,000
Coinsurance
(Member’s responsibility)
20% after
deductible up to
out-of pocket max.
50% after
deductible up to
out-of pocket max.
$0 once out-of-pocket max. is satisfied
Coinsurance Maximum
Individual
Family
$3,000
$6,000
$7,500
$15,000
Out-of-Pocket Maximum
Individual
Family
$4,250
$8,500
$10,000
$20,000
Includes deductible
Lifetime Maximum* per insured
$1,000,000
Non-Specialist Office Visit
Unlimited visits
General Physician, Family Practitioner, Pediatrician or Internist
Not covered Not covered
Specialist Visit
Unlimited visits
Not covered Not covered
Hospital Admission
20%
after deductible
50%
after deductible
Outpatient Surgery
20%
after deductible
50%
after deductible
Urgent Care Facility
Not covered Not covered
Emergency Room
$100 copay** (waived if admitted)
20% coinsurance after deductible
Annual Routine Gyn Exam
No waiting period, no calendar year max.
Annual Pap/Mammogram
$0 copay
deductible waived
50%
after deductible
Maternity
Not covered
Except for pregnancy complications
Preventive Health — Routine Physical
Aetna will pay up to $200 per exam*
$25 copay
deductible waived
50%
after deductible
Includes lab work and X-rays
Lab/X-Ray
++
Not covered Not covered
Skilled Nursing — in lieu of hospital
30 days per calendar year*
20%
after deductible
50%
after deductible
Physical/Occupational Therapy and Chiropractic Care
Aetna will pay up to $2,000 per calendar year*
Not covered Not covered
Home Health Care — in lieu of hospital
60 visits per calendar year*
20%
after deductible
50%
after deductible
Durable Medical Equipment
+++
Aetna will pay up to $2,000 per calendar year*
Not covered Not covered
PHARMACY
Pharmacy Deductible
per individual
Not Applicable Not Applicable
Generic
Oral Contraceptives Included
$15 copay $15 copay plus 50%
Preferred Brand
Oral Contraceptives Included
Not covered
Aetna Discount Applies
Not covered
Non-Preferred Brand
Oral Contraceptives Included
Not covered
Aetna Discount Applies
Not covered
Calendar Year Maximum
per individual*
Unlimited Unlimited
* Maximum applies to combined in and
out-of-network benefits.
** Copay is billed separately and not due at time
of service. Copay does not count towards
coinsurance or out-of-pocket maximum.
+ Payment for out-of-network facility care is
determined based upon Aetna’s Allowable
Fee Schedule. Payment for other out-of-
network facility care is determined based
upon the negotiated charge that would apply
if such services or supplies were received from
a Preferred Provider.
++ Except for coverage of services related to
diagnosis, treatment and management
of Osteoporosis. Mastectomy and related
procedures.
+++ Coverage for diabetic equipment, supplies
and self-management training/education.
A summary of exclusions is listed in the Aetna
Advantage Plan brochure. For a full list of
benefit coverage and exclusions refer to the plan
documents. Plans may be subject to medical
underwriting or other restrictions. Rates and
benefits vary by location. 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. Health
insurance plans contain exclusions and limitations.
Material subject to change.
