Oklahoma Small Group Enrollment Guide Your Aetna plan features,

Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Oklahoma Small Group
Enrollment Guide
Your Aetna plan features,
and how to sign up
www.aetna.com
14.02.965.1-OK E (6/12)
Learn about:
Member tools, how to enroll,
and value-added programs.
2
Health/Dental benefits, health/dental insurance and life insurance plans/policies are offered and/or underwritten by Aetna Health Inc. and/or Aetna
Life Insurance Company (Aetna). Each insurer has sole financial responsibility for its own products.
Welcome to Aetna!
At Aetna, we know that the true worth of any health benefits
and insurance plan is how it works for you and your family.
Aetna also recognizes all families are different, each with their
own unique needs. Some families need a plan with lower
out-of-pocket costs when they see their doctor; some need
lower monthly premiums; and some need the option to seek
out-of-network care. With Aetna, each family can pick the plan
that best suits their unique individual needs. The choice is yours!
Plus, each health plan from Aetna offers a number of valuable
member tools and resources to help you and your family make
more informed decisions about your health and well-being.
Whether it’s finding a doctor online, checking the status of a
pending claim, or finding the lowest-cost prescription for you
and your family, Aetna provides you with the tools you need to
manage your care.
Table of Contents
Aetna Navigator® secure member website
4
Personal Health Record 6
Aetna’s health care transparency tools
7
Employee Assistance Program (EAP)
7
RelayHealth®8
9
Informed Health® Line Walk-in clinics 9
Urgent care
9
Special programs for the special needs of women
9
10
Aetna Fitness SM discount program
11
Aetna Weight Management SM discount program
SM
13
Aetna Hearing discount program
14
Aetna VisionSM discount program
14
Aetna Natural Products and Services SM discount program
Preventive care
16
Medical products
17
Dental products 19
Aetna’s Group Life Insurance for employees 20
Getting to know your Aetna prescription drug plan 21
How will I find a doctor or specialist?
23
How to complete the enrollment form application 24
Your member ID card
25
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Aetna Navigator®
our secure member website
When you need up-to-date information about your health
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.
Aetna members can turn to Aetna Navigator, our secure member
website, that provides you with a single source for online health
and benefits information. It’s convenient, and easy to use:
•Simple Steps To A Healthier Life® is an interactive online
health and wellness program that can help employers enhance
the health and productivity of their employees and support a
more complete system of care.
The program can help employers:
1. Go to www.aetna.com.
2. Click on Log In.
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 anytime of the day
or night — from wherever you have Internet access.
Our secure website lets you:
•Print temporary ID cards.
•View information about who is covered on your plan.
•Find doctors, pharmacies or hospitals on our DocFind®
online provider directory.
•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
•E stimate 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 Aetna’s mail-order
pharmacy, Aetna Rx Home Delivery®; search and learn
about medications; and review the medications available on
Aetna’s formulary
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*If Included in your plan.
--Promote health risk reduction.
--Keep healthy people healthy.
--Build employee responsibility for making informed
health decisions.
--Support business goals to help improve employee health
status and productivity.
--Gain valuable insight to help make strategic decisions for
offering employee benefits.
--Integrate with Aetna services and other health outreach
programs.
Simple Steps To A Healthier Life helps participants turn
knowledge about their 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.
•Aetna SmartSourceSM delivers relevant health information
that’s specific to each member, based on where they live, their
Aetna health plan, and other information. Aetna SmartSource
scans Aetna’s vast resources to bring members, in a single
search:
--Specialists in their local area.
--Related medications, treatment options and estimated
health costs.
--Aetna programs that may help them manage their condition.
--Easy-to-understand health articles and tips .
•Aetna InteliHealth® website, our 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
--Features interactive and streaming videos about topics such
as asthma and heart health
No-Cost Health Incentive Credit
Earn $50 in just a few simple steps
You earn a $50 credit toward your out-of-pocket expenses
when you:
•Complete or update your Health Assessment on Simple Steps
To A Healthier Life®.
•And, complete one Online Wellness Program (includes both the
initial questionnaire & program survey 30 days after
completion of the program).
If your spouse is covered under the plan, he or she is also eligible
for the same incentive credit. So a family could save $100 in
out-of-pocket expenses each year. Incentive rewards will be
credited toward the deductible and maximum out-of-pocket
limit. This program is included at no additional cost on all plans
except Health Savings Account (HSA) compatible plans.
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Personal Health Record
Put your Personal Health Record to work and make history!
Members with Aetna medical coverage can now use Aetna’s
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:
Aetna’s 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 now
Information from your Aetna health claims automatically appear
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 also can 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 may also receive a
message if there’s an alternative treatment that may improve
your care. And, if you give Aetna permission, you can get e-mails
telling you that a new alert or reminder is in your secure Personal
Health Record.
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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.
* T he Aetna Personal Health Record should not be used as the sole source of information about the member’s health history.
Aetna’s health care
transparency tools
Since 2005, Aetna has empowered members with our suite of
member tools that inform you about doctors, hospitals and
other medical facilities. You can make more informed health
care decisions by using our online transparency tools before
visiting a doctor or hospital.*
Our transparency tools allow you to:
•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.
Your access as a member to this combination of physicianspecific rates, clinical quality and efficiency data, and
facility-specific medical procedure costs is a first from a national
health carrier and demonstrates our commitment to you.
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:
•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.
Employee Assistance Program (EAP)***
Aetna’s Employee Assistance Program is a confidential program
that gives employees and members of their household access to
useful services and support to help them manage the everyday
challenges of work and home. The EAP is available at no charge
to members and their family members and includes:
Choice — They’ll find a range of resources to help them balance
their personal and professional lives.
asy access — EAP representatives can be reached anytime toll
E
free at 1-866-672-5417 or on the web at www.aetnaeap.com.
rofessional assistance — Our workplace-trained specialists
P
provide confidential phone support, assessing needs and
recommending an appropriate course of action. Employees and
their household members receive three phone consultations per
member in a calendar year.
Employers can also take advantage of EAP Resources:
anagement and human resources assistance —
M
Employers get unlimited phone consultations with
workplace-trained clinicians who can provide help in dealing
with complex employee issues that may arise.
nline tools — Employers can also get online tools and
O
materials to encourage employees to use the EAP by visiting
www.aetnaeap.com (enter your company ID and select the
“Promotional Materials” link).
*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.
***EAP is administered by Aetna Behavioral Health, LLC and Aetna Life Insurance Company.
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RelayHealth®
Visit your doctor online with
webVisit®
Aetna’s 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 through RelayHealth links
you with your doctor, Aetna health
plan and pharmacy in a single
secure network.
webVisit is easy to use:
1. E nter the RelayHealth website for non-urgent medical care.
2. C
omplete 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.
Simply register on the RelayHealth website at
https://www.relayhealth.com/Patients/Registration.aspx
to get started.
Once registered, log in at your convenience to take advantage of
the many features available to registered members, in addition
to the webVisit service:
•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
What’s the difference between online RelayHealth site
and e-mailing my doctor?
e-mail
webVisit
•May not be secure or HIPAA (Health Insurance Portability and
Accountability Act)-compliant.
•Free form — you may not know the medical questions to
address so your doctor can diagnose your ailment.
•Non-chargeable — eligibility needs to be determined, and
you must submit a claim.
•HIPAA-compliant — secure and authenticated with user log-in.
•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.
A few things to note before you get started:
•You must have an established relationship with a doctor before
webVisit can be used.
•Your doctor must be a member of Aetna’s network and be
registered as a participating provider in the RelayHealth
physician network — participating providers are identified on
DocFind through the Aetna Navigator.
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*Employees need to do nothing as this service will be automatically added to their coverage. This feature does not apply to any HMO plan a prospective member
may choose. Plan sponsors offering traditional plans can customize the copay required for an online visit (webVisit). This service includes plans that have health
funds when the fund limit is exhausted. Physicians will be paid for services provided according to the terms of their contract. As always, a member’s financial
responsibility depends on the terms of his or her plan, which may vary.
Check your service area for availability.
Informed Health® Line
Access to a registered nurse — 24/7!
With Aetna’s 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.
Walk-in clinics
Looking for a convenient way to get medical care? Consider a
walk-in clinic. It’s a convenient alternative to the doctor’s
office. If you aren’t feeling well and have trouble getting an
appointment with your doctor, it’s your answer to non-emergency
care right away.
And walk-in clinics are not just for when you are sick. You might
be surprised by the full spectrum of services available at a
walk-in clinic, many of which are staffed by physician assistants
and nurse practitioners. They offer:
•Treatment for minor burns, stings or bites, strains, and cuts
•C are for earaches, flu and cold symptoms, sinus infections,
and allergies
•Physicals and pediatric and gynecologic services
•Flu shots and other vaccinations
•X-ray and lab services
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, whereas walk-in clinics are staffed by nurse
practitioners to care for minor ailments. And just like walk-in
clinics, some 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 a walk-in clinic or
urgent care center.* To find the closest clinic or 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
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
Aetna’s 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
A convenient solution for care
on the go
*Oklahoma HMO members must contact their medical group or primary care physician for walk-in clinic and urgent care center use.
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Aetna FitnessSM discount program
There are a million reasons to get fit
How to save on a gym membership
To name a few — you’ll look and feel better. When you have a
healthy weight, you can also lower your risks for heart disease,
high blood pressure, diabetes … even depression.
You can choose and save at over 10,000 gyms* (and growing) in
the GlobalFit® network. So it’s easy to find one near work or home.
And with the Aetna Fitness discount program, you can save, too.
Just for taking good care of yourself.
What you get with the program
You can:
•Save on gym memberships.
•Save on treadmills, elliptical trainers and more.
•Try an at-home weight-loss program.
•Get health coaching to stop smoking, lower stress and more.
Try a gym for free
You can get a free guest pass at most gyms. It’s a great way to
check out the gym culture, services and equipment before you
sign up. To get yours, visit www.globalfit.com/fitness.
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*GlobalFit website, www.globalfit.com/fitness, 1/12.
Three easy steps:
Step 1: Visit www.globalfit.com/fitness to find a gym.
Step 2: Pick a gym, and follow the steps to sign up online.
Step 3: Print your confirmation and you’re set to go!
You can also call 1-800-298-7800 to sign up.
Keep in mind that this offer is for new gym members only. If you
belong to a gym now, or belonged recently, you may not be able
to get discounts at that gym.
More reasons to join a gym through GlobalFit
What else you get:
You can:
•When you join the annual program, you can also choose
to receive a free copy of The CalorieKing Calorie, Fat and
Carbohydrate Counter book3, with free shipping. You can take
advantage of this free offer at any time during your first
year of membership.
•Personalized goals based on your body and circumstances.
•Lessons and interactive tasks that guide you through the
stages of weight loss and weight maintenance.
•Access to CalorieKing’s Food and Exercise Diary, and
extensive food database, to monitor your personal calorie
management progress.
•Access to CalorieKing’s member-only social network of
forums, blogs and interest groups and much more!
•Choose from flexible membership options.
•Get easy billing through your bank account or major credit card.
•Visit a participating gym when you travel.*
•Transfer your membership to another participating gym or
another person.*
•Freeze your membership for up to two months per calendar year.*
•Plus — your family members on your health plan can use the
program, too!
Save on home exercise equipment, too
Rather get fit in your own home? You can do that, too.
You’ll get discounts on:
•Elliptical trainers.
•Treadmills.
•Resistance bands, mats, yoga accessories, and more!
More support for your healthy lifestyle
Getting fit is just the start to a healthier you.
You can also:
•Try out an at-home weight-loss program.
•Get one-on-one health coaching** to help you quit smoking,
lower stress, lose weight and more.
Aetna Weight Management SM discount program
Lose weight and feel great! It’s easier with the Aetna Weight
Management discount program.
You can save on some of today’s most popular weight loss
programs, meal and diet plans from CalorieKing®, eDiets®,
Jenny® and Nutrisystem®.
Save on CalorieKing
You can join an annual or monthly CalorieKing Program and try
out the program free for 7 days.
Program options:
Save on eDiets
Save4 on the eDiets Meal Delivery Plan, eDiets Online Diet Plan
and purchases from the eDiets Online Store.
eDiets Diet Plans
Program Options:
•Save on the eDiets Meal Delivery Plan (5-day or 7-day) cost of
food, delivered right to your door.
•Save on the price of your monthly or annual membership when
you enroll in the eDiets Online Diet Plan.
What else you get:
•One-on-one professional support.
•Customized menus, recipes and convenient food options.
•Live phone, chat and e-mail support from certified and
registered dieticians.
•Easy-to-use diet tools such as eDiets Nutrition Tracker,
Food Journal, Dining Out Guide.
•24/7 online member support and much more!
eDiets Online Store
Save on all purchases from the eDiets Online Store. Choose from
DVDs, CDs, fitness and exercise equipment, vitamins and
supplements, and more.
•Join an Annual or Monthly CalorieKing Program and take
advantage of a 7-day free trial period.1
•Then get a discount when you continue your Annual Program
membership. 2
•With an Annual or Monthly Program membership, you also
save when you buy products from the CalorieKing Store.
*Not available for month-to-month memberships.
**By WellCall, Inc., through GlobalFit.
1You can cancel your program membership at any time during the first 7 days by logging into the program and following the instructions in “Payment and
Account Details” under “Account Settings.” If you do not cancel during the first 7 days your credit card will be charged on the eighth day.
2I f you are already a CalorieKing member you will need to terminate your current CalorieKing Account and rejoin to receive the Aetna discounted
membership price.
3Offer good in the continental United States, Alaska and Hawaii only.
4 If you are already an eDiets member, you will need to cancel your current membership and re-enroll to receive the Aetna member discounted rate.
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Save on Jenny
Choose from a wide range of program options to meet your
individual needs and weight loss goals.
Program options:
•Start with a FREE 30-Day Program.1
•Then get a discount on a Jenny Premium Program1 available at
participating Jenny centers and through Jenny At Home.
What else you get:
Visit Aetna Navigator,
our secure member
website at www.aetna.com
for more details about the
Weight Management
discount program.
•Weekly one-on-one scheduled consultations.
•Planned and personalized menus.
•Plans to help you get active and stay motivated.
•Online support and free Jenny eTools.
•Customer care support by calling 1-800-JennyCare (536-6922).
•Message boards, live chat and much more!
Save on Nutrisystem
Enroll in a Nutrisystem weight loss meal plan and choose from
over 130 menu items that help you control portion size and are
easy to make.
Program options:
•Save on any 28-Day Nutrisystem® SuccessTM weight loss
meal plan. 2
•Get other offers available from Nutrisystem at the
time you enroll.
•Get even bigger discounts with Auto-Delivery. 3
What else you get:
•Tasty food and an easy-to-follow meal plan.
•High-quality protein shakes for optimized nutrition.
•My Daily 3TM personalized activity plans to help you get moving.
•Transition and maintenance plans to help you keep the weight off.
•Convenience, online tools, FREE coaching that Nutrisystem is
known for and, much more!
1Plus
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the cost of food. Plus the cost of shipping, if applicable. Offer applies to initial membership fee only and is valid at participating centers in the U.S., Canada
and Puerto Rico and through Jenny At Home. Each offer is a separate offer and can be used only once per person. Restrictions apply.
2The 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. If you are enrolled in Auto-Delivery, you must cancel it and then re-enroll to receive the discounted rate.
3Offer good on new 28-day Auto-Delivery programs only. With Auto-Delivery, you receive at discount off Nutrisystem’s regular 28-day program price and free
shipping to continental United States only.
Aetna HearingSM discount program
Advantages of Aetna Hearing discount program
The Aetna Hearing discount program helps you and your family
save on hearing exams, hearing aids and other hearing services.
You can choose between two great offers at no additional
premium cost:
•Hundreds of locations nationwide
•Discounted rates for hearing exams
•Thousands of hearing aid models to choose from
•Savings on batteries and routine services (cleanings,
instrument checks and battery door replacements)
•Hearing Care Solutions
•HearPO®
Please call each vendor directly for program details.
Hearing Care Solutions 1-866-344-7756
HearPO 1-888-HEARING (1-888-432-7464)
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What you save*
Aetna VisionSM discount program
See better for less
Product or Service
What You Pay
Eye exams
(For plans that cover eye exams)
See your plan documents
for details.
Eye exams (For plans that DO NOT cover eye exams)
Complete eye exam
$42
Standard contact lens
fit and follow-up
$40 (plus $42 exam fee)
Specialty contact lens
fit and follow-up
(for example, toric, bifocal,
gas permeable)
$10 off retail
(plus $42 exam fee)
Lenses (per pair, uncoated plastic)
Program locations
Choose from thousands of national chains such as:
• Pearle Vision® Centers
•Sears® Optical
•LensCrafters®
•Target® Optical
• JCPenney® Optical
Plus, you can go to many eye doctors in private practice. To find
one near you, go to www.aetna.com or call 1-800-793-8616.
Single vision
$40
Bifocal
$60
Trifocal
$80
Standard progressive
(no-line bifocal)
$120
Aetna Natural Products and ServicesSM
discount program
40% off retail price
Save on good health
Eyeglass frames
Lens options, per pair (add to lens price above)
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This program helps you save on what you need to see better,
like eye exams, glasses, contacts … even LASIK. You also pay less
for vision items that don’t need a prescription. So pick up some
shades for the summer or stock up on contact lens cleaner.
There are plenty more savings where those came from!
Standard polycarbonate
(includes ultraviolet and
scratch-resistant coating)
$40
Scratch-resistant coating
$15
Ultraviolet (UV) coating
$15
Solid or gradient tint
$15
Standard
antireflective coating
$45
Glass
20% off retail price
Photochromic glass
20% off retail price
Find a program provider at www.aetna.com. Then take your
Aetna ID card to your appointment for savings on the spot.
You get the Aetna Natural Products and Services discount
program to help. You can save on massage therapy, natural
products, online provider consultations and more.
You get the program at no extra cost
Contact lenses
15% off retail price
(5% for disposables)
Contact lens
replacement by mail
Call 1-800-391-5367 to
order a new pair.
More vision items
20% off retail price
LASIK eye surgery
15% off retail prices
(5% off special advertised
prices) for U.S. Laser
Network services. You must
call 1-800-422-6600 to
schedule an appointment.
It’s built right into your Aetna benefits and insurance plan. And it
helps you save on services health plans normally don’t cover.
Once you’re an Aetna member, just log in to Aetna Navigator, our
secure member website at www.aetna.com to start saving.
Save on natural therapy services
Save off the normal fee for these services though the
ChooseHealthy® program:**
•Massage therapy, to release tension and improve circulation.
•Acupuncture, to heal areas of pain or stress with the
use of needles.
•Chiropractic care, to ease neck and back pain by
adjusting the spine.
•Dietetic counseling, for advice from registered dieticians
on the foods you should eat.
How to start
Find a program provider at www.aetna.com. Then take your
Aetna ID card to your appointment for savings on the spot.
*EyeMed Services and Compensation Schedule, 3/09. Prices are subject to change. Discounts may not be available on certain brand-name vision materials
(that is, designer eyeglass frames) on which the manufacturer imposes a no-discount practice.
**T he ChooseHealthy program is made available through American Specialty Health Networks, Inc. (ASH Networks) and Healthyroads, Inc., subsidiaries of
American Specialty Health Incorporated (ASH). ChooseHealthy is a federally registered trademark of ASH and used with permission herein.
Save on over 2,400 health and wellness products
How to start
You get discounts off the retail price through the ChooseHealthy
program. Free standard shipping, too.
Log in to Aetna Navigator, our secure member website at
www.aetna.com. To start your consultation, just choose a
condition and answer a few questions.
Get discounts on:
•Over-the-counter vitamins.
•Herbal and nutritional supplements.
•Aromatherapy products.
•Homeopathic remedies.
•Natural body care products.
•Yoga equipment and more.
How to start
You can order by phone or the web. Visit Aetna Navigator, our
secure member website at www.aetna.com for details.
Get medical consultations online — and save
You’ll get access to a network of medical doctors —
the Vital Health Network.
These doctors can help you enhance your body’s ability to
prevent disease by using its natural powers.
After you connect with the doctor online, you’ll get a customized
treatment plan for healthy living. Just visit Aetna Navigator to
view your plan.
No paperwork, no waiting
The Aetna Natural Products and Services discount program
is easy to use. You can start saving as soon as you’re an
Aetna member!
More advantages:
•No referrals
•No claim forms to mail in
•No limits on how many times you can save
If your plan covers any of these services, figure out your plan
costs before using these discounts. You could pay less that way.
You get:
•Advice on natural remedies for joint pain, allergies, headaches
and many other conditions.
•Secure messaging with a Vital Health Network doctor on the
topic you choose.
•Discounts off the retail price of one online consultation.
•Additional discounts off the retail price of two or more online
consultations.
15
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porerument quiam resed eum
ditium Em facepere cuptati dis
doloresed magnimus anditem
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quidem et odis.
Aetna Health Connections disease management
Prevention programs —
helping you and your family stay healthy
Preventive care
Aetna Health ConnectionsSM disease management
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.
This program features Aetna nurses and programs, including
MedQuery®, and is an important part of our new Aetna
Health Connections health and wellness portfolio. Our newly
redesigned capabilities support 35 conditions and integrate care
for members with multiple conditions. The program includes
cutting-edge technology to help improve patient safety,
doctor communication and more.
Member health education reminders
To help prevent, detect and monitor problems early on, we
mail women age 40 and over reminders encouraging them
to schedule an annual mammogram. 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.
This integrated, holistic approach using capabilities unique to
Aetna delivers premier medical management for our members
that no one in the industry can match. It includes innovative
and individualized clinical programs, information and support
for totally integrated health management that optimizes our
members’ state of health. Members are viewed holistically —
considering multiple diseases or conditions across all benefits
plans — to deliver customized programs based on their
individual needs and preferences.
SM
program conditions and content
16
Vascular
Pulmonary
Neuro-Geriatric
Renal
•Heart failure
•Diabetes —
adult & pediatric
•Coronary artery disease
(CAD)
•Peripheral artery disease
(PAD)
•Hypertension —
adult & pediatric
(high blood pressure)
•Cerebrovascular disease/
stroke (CVA)
•Hyperlipidemia
(high cholesterol)
•Asthma — adult & pediatric
•Chronic obstructive
pulmonary disease (COPD)
•Geriatrics
•Migraines
•Seizures
•Parkinsonism
•Chronic kidney disease
•End stage renal failure
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
*Not scored by Clinical Stratification and Identification (CSID) process.
Aetna
is the brand
as a comorbid
…
condition.
**Addressed
Cancer
•General cancer
•Breast cancer
•Lung cancer
•Lymphoma/Leukemia
•Prostate cancer
•Colorectal cancer
Other
• Weight management
— adult & pediatric
•Cystic fibrosis —
adult & pediatric
•HIV
•Hypercoagulable state
•Sickle cell disease —
adult & pediatric
•Depression**
Medical Products
How do I pick the right health benefits and insurance plan?
Plan features
Savings
OAMC
Plus
HMO HNOption OAMC HSA
Coverage for
preventive care
•
No PCP
requirement
•
•
•
•
•
•
•
•
No referrals
•
•
•
•
Out-of-network
access
•
•
•
•
No claim forms
•
•
•
•
•
Aetna’s provider network in Oklahoma has more than 15,401
physicians and 381 hospitals.* So whichever plan you choose,
you will be able to find the provider to best suit your needs.
HMO Network = 4,191 doctors and 77 hospitals
Managed Choice Network/OAMC = 5,598 doctors and
152 hospitals
Use DocFind to search for a provider
or select a primary care physician
(PCP).
www.aetna.com/docfind
A fund established
to pay for eligible
out-of-pocket
health care
expenses
•
Tax Preferred
Account
•
Call the Member Services number
on the back of your ID card to order
a provider directory.
*According to the Aetna Enterprise Provider Database as of January 31, 2012. Network subject to change.
17
Choose the right health plan for you and your family
in three easy steps:
Health care terms to know
1. How much are you spending?
Premiums are the amount you pay for your insurance
policy, often deducted from your paycheck.
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. W
hat 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 should a major medical condition develop.
•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.
18
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.
Coinsurance maximum or maximum out-of-pocket
expense is the maximum amount you’ll have to spend
before all of your medical bills are covered by the
medical plan. Sometimes, certain services, such as
pharmacy, may not count toward the coinsurance
maximum. Copayments may still apply.
Dental Products
How do I pick the right dental benefits and insurance plan?*
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
1-888-702-3862
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.
1M ayoClinic.com. “Oral health: A window to your overall health.” Available at www.mayoclinic.com/health/dental/DE00001. Accessed May 2010.
2R .C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. “The potential impact of periodontal disease on general health:
a consensus view.” Current Medical Research and Opinion, Vol. 24, No. 6, 2008, 1635-1643.
19
Aetna Life Insurance Company
plans protect you from financial loss.
Nothing is more reassuring than knowing financial resources are
available when you need them most. Aetna’s products provide
your dependents financial support when it counts.
Protection for the future
You’ll be glad to know that if your employer selects Aetna to
offer you a variety of life insurance products, with more than
150 years industry experience, your future is in good hands.
Basic Term Life
The building block of financial security. You get companysponsored protection with flexible benefit schedules and
guaranteed coverage up to a designated amount.
20
Dependent Term Life
Financial protection for your spouse and dependent children.
AD&D Ultra®
This leading-edge product provides you better financial security
than typical accidental death and dismemberment 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.
Getting to know your
Aetna prescription drug plan
Know what drugs are covered
Start your Aetna plan with peace of mind
You and your doctor can choose from hundreds of quality,
cost-effective drugs. Your plan covers brand-name and generic
drugs on the Aetna Preferred Drug List. (You may also see this
called a “formulary.”) It was developed based on advice from
many different health care specialists. And all drugs on it are
approved by the U.S. Food and Drug Administration (FDA).
New plans often come with new rules. We want to help make
the change easier. Once your plan starts, you don’t have to
worry about getting approval for most covered drugs for your
first 90 days.
In your first 90 days:
To see this list or learn about medication alternatives, go to
www.aetna.com/formulary.
•If you need a covered drug that normally needs approval first,
you’ll be able to get that drug without the approval.
•For clinical reasons, some drugs will still need to be approved
first, even in your first 90 days. This may be because of
questions about dosing, quantity or other health concerns.
Understand precertification and how it helps you
After 90 days:
Some drugs need precertification before your plan will cover
them. This simply means we need to approve them first for you.
Doing this helps make sure the drug is being used at the right
dose, for the right reasons. This helps keep you safe. It can also
help you find another drug that costs less and is just as effective
— something you could talk about with your doctor.
•You will need approval for any new drugs that your doctor
prescribes that would normally require precertification.
•Any prescription you filled during the first 90 days will still be
covered as long as you get the drug at the same strength and
quantity as originally prescribed.
•If your doctor changes the dosage of your medication, you
may then need to get it approved first. This will happen if the
dosage is more than what the FDA recommends.
Your plan also covers many drugs that are not on this list.
Remember though, you’ll often pay less for drugs on our list.
Your doctor will contact us by phone, fax or e-mail. If your
request is not approved and you still want the drug, you will
have to pay the full price of the prescription.
All decisions are made based on FDA guidelines and current
medical findings. Learn more about this at
www.aetna.com/formulary.
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.
Claritin® is a registered trademark of Schering-Plough HealthCare Products Inc.
Prilosec® is a registered trademark of AstraZeneca LLP.
21
Specialty Pharmacy Medications
With your new Aetna Specialty CareRx SM benefit, you can get
your first fill at a retail pharmacy. In order to receive coverage,
your second fill and all other refills will need to come from a
participating specialty pharmacy.
For a full list of specialty pharmacy medications, please visit
www.aetnaspecialtycarerx.com.
Limitations and Exclusions
Drugs that are not covered under the standard prescription drug
benefit program include, but are not limited to:
•Drugs used for weight loss, including the treatment of obesity.
• Over-the-counter drugs.
• Nutritional supplements.
•Smoking cessation aids or drugs.
• Growth hormones.
•Prophylactic drugs for travel.
•Test agents and devices, other than diabetic test agents.
•Performance, athletic performance, or lifestyle enhancement
drugs and supplies.
•Cosmetics or any drugs used for cosmetic purposes or to
promote hair growth, including health and beauty aids.
•Replacement for lost or stolen prescriptions.
For a complete list of what is not covered by your prescription
drug plan, refer to your plan documents after enrollment.
22
Find out more
Once you are enrolled, log in
to Aetna Navigator, our secure
member website at
www.aetna.com.
You’ll find benefits and claims
information, the Preferred Drug
List, cost estimates and more.
You can also refer to your
Summary of Benefits or call us at
the toll-free number on your
Aetna member ID card.
How will I 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. You also may search for a particular physician by
name, specialty or other options.
How to find your Oklahoma plan
When performing a search in DocFind, you will be asked to select a
plan name. Some of the names of our Oklahoma plans appear by
their network names. Here is a quick reference to identify your plan:
Medical plan name as it
appears in DocFind
Common plan
names
HMO
HMO
Open
Choice®
PPO
Managed Choice® POS (Open Access)
Managed
Choice®
POS (Open Access)
PPO
OAMC
OAMC HSA
Savings Plus
Savings Plus
HNOption
Health Network
Option
23
How to complete
the enrollment form application
Please be sure to complete your enrollment form thoroughly.
The sections noted below are frequently overlooked.
1. D
ate of hire.
2. S elect the medical plan(s) offered by your employer.
If dental plans are offered, select your dental plan next.
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 pages 2 and 3 are not visible.
Oklahoma Employee Enrollment/Change Form
3. Insert your Social Security number here.
(2 - 100 Eligible Employees)
Member Aetna ID Number (if available)
4. Enter your doctor’s (and dentists if enrolling in a DMO plan)
ID number if enrolling in a HMO plan.
Employer Name
Effective Date
1
5. Sign here if you are waiving coverage for yourself
or any dependents.
2
6. S ign and date here to complete the form.
Social Security Number
D. Dependent Information
List any dependent in Section C
living at another address.
If any dependent’s last name
differs from yours, explain.
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 B and G.
Change of coverage
Employee Termination
COBRA
State Continuation for:
Add Spouse/Domestic Partner/
Remove Spouse/Domestic
Employee
Dependent
Dependent Child
Partner/Dependent Child
Length of Continuation:
Name Change
Cancel Coverage
18
36
Other
Other
Original Qualifying Event Date
New Hire
Rehire/Reinstatement
New Group Enrollment
Late Enrollment
Other
Date of Hire
Control/Group No.
Suffix
Account
Plan No.
2
Class Code
1. Medical - Check one.
Aetna HMO Plan –
Plan
Aetna Open Access MC Plan –
Plan
Aetna PPO Plan –
Plan
Aetna Health Network Option (HNO) –
Plan
Aetna Savings Plus –
Name:
Reason:
Plan
Aetna Indemnity Plan
3
Reason
A. Coverage Selection – Please print clearly, using black ink. (Shaded sections for Employer/Aetna Use Only)
Name:
Control/Group No.
Suffix
Account
2. Dental - Check one.
Standard Plans:
Option:
For FOC: DMO®
or PPO
Voluntary Plans:
Option:
For FOC: DMO®
or PPO
Plan No.
Control/Group No.
Suffix
Account
Plan No.
3. Life and Disability
Basic Life/AD&D Ultra®
Optional Dependent Life
Life & Disability Packaged Plan
Beneficiary Designation - Full Name (First, Middle, Last)
Beneficiary Social Security Number
Before today, were you covered under this
Yes
No
employer’s dental plan?
Relationship to Employee
Address:
Packaged Dental/Life/Disability Plan
Reason:
B. Employee Information - Must be completed by the employee.
Social Security
FOR Dependent Life – If age +19 and a full-time
student,Number
provide the following: Last Name, First Name, M.I.
Child Name
Job Title
School Name
Expected Graduation Date
Home Address
Apt. No.
Work Address
City, State
Home Telephone
Number of Credit Hours
City, State
ZIP Code
ZIP Code
Work Telephone
E. Race/Ethnicity – Optional (This information is designed for the purpose of data collection and will not be used for determining eligibility, rating or claim payment.)
1. Employee
2. Spouse/DP
3. Child/Stepchild/Other
4. Child/Stepchild/Other
5. Child/Stepchild/Other
White – 01Salary African AmericanHourly
or Black – 02No. of HoursHispanic
Latin One
– 03
Asian – 04
Worked orCheck
1099 – 04
White – 01
African AmericanWeekly
or Black – 02Per Week Hispanic or LatinFull-Time
– 03
Asian
Retiree
White – 01$
African AmericanMonthly
or Black – 02
Hispanic or LatinPart-Time
– 03
Asian
– 04
White – 01SubscriberAfrican
Black
02
Hispanic
– 03 (que no sea
Asian
– 04
PrimaryAmerican
Language or
(other
than– English)
Primer
IdiomaordelLatin
suscriptor
el Ingles)
What
is
your
primary
Language?
White – 01
African American or Black – 02
Hispanic or Latin – 03
Asian – 04
Other – Marital
05 Status
No. of Dependents Including
Seasonal
Other – 05 Single
Divorced
Legally Separated Spouse/Domestic Partner
Temporary
Other – 05 Married
Widowed
OtherDisability
– 05
Subscriber
Do you
have– a05disability which affects your ability to communicate or read?
Yes
No
Other
If Yes, please indicate the nature of your disability.
¿Cuál es su primer idioma?
F. Other Insurance
C. Individuals
- List
whom you
are HMO,
enrolling
or source,
adding/changing/removing
coverage.
additional sheets if necessary.
If you have checked “Yes” to Other Health Coverage
(Section C), Covered
provide name
and individuals
policy numberfor
of insurance
carrier,
or other
a copy of the insurance card,
and start Attach
date of the
coverage.
NOTE: Enter Domestic Partner ONLY if your employer has elected that coverage.
NOTE
FORC),
MEDICAL
ANDand
DENTAL
COVERAGE:
While
theHMO,
Federal
Patient
Protection
Care
mandates
coverage of dependent children up to age 26,
If you have checked “Yes” to Other Dental Coverage
(Section
provide name
policy number
of insurance
carrier,
or other
source,
a copy ofand
the Affordable
insurance card,
andAct
start
date of the
your plan may allow coverage beyond age 26 for medical plans and some dental plans. Some exceptions apply. Please refer to your plan documents or contact your
coverage.
ChildCarrier Name
Stepchild
Name of Covered Individual
Other
Group Number
TerminationMedical
Date
Start Date
Dental
Life
3.
G. Declination/Waiver of Coverage -
Stepchild
4
Dental Office ID
Number
(if applicable)
Yes
Yes
Health
Yes
No
Yes
Medical
Dental
To be 4.
completed if medical and/or dental coverage is declined or refused by an eligible employee and/or their eligible Life
family members.
Child
Primary Office
ID Number
(if applicable)
Current Patient
PROOF OF PRIOR MEDICAL COVERAGE – IMPORTANT (Required)
Coverage
Sex
Birthdate
Failure to provide Proof
of Prior Coverage
may subject you or a
Namehave
(Last,prior
First,coverage?
M.I.)
M/F
Social
Number
(MM/DD/YYYY)
Does anyone age 19 and over enrolling on this enrollment form
Yes
No Security
family
member (age
19 and over) to theElection
full pre-existing conditions
If “Yes,” provide the information requested in the
table below.
limitation with no credit for prior coverage.
You may
a Yes
Yes
Yes request
Yes Yes
Employee
Medical
Proof of coverage should accompany this enrollment form for pre-existing condition credit if enrolling
Certificate of Creditable Coverage from Dental
your prior carrier. NOTE: N/A
1.
in other than an HMO plan. Acceptable forms of proof are:
Life/Dis provision, the preIf your Plan contains a pre-existing conditions
1. Certificate of Creditable Coverage from priorSpouse
carrier, or Domestic Partner (DP)
Medical
existing conditions exclusion and limitation
does not apply to a
N/A
Dental
2. Copy of ID card or most recent payroll stub
showing medical coverage deduction, or
person under 19 years of age.
2.
Life
3. Copy of most recent medical premium bill from prior carrier.
Current Patient
Student -(+19)
(Life Only)
4
Prior Dental
Coverage
Other Dental
Coverage
Other Health
Coverage
(A)dd
(C)hange
(R)emove
Incapacitated
benefits
administrator.
Yes
No If “Yes,” provide name and address of spouse/domestic partner’s employer.
Is your Spouse/Domestic Partner employed?
Other
No
Medical
Stepchild
1. Medical Coverage Declined for:
ReasonChild
for Declining
Coverage:Other
Parental group coverage
Dental
Myself
Children
5.Spousal/domestic partner group coverage
Retiree coverage
Life
Spouse/Domestic Partner
Another group plan provided by my employer
TRICARE or CHAMPVA
2. Dental Coverage Declined for:
COBRA
coverage
Medicaid
GR-68753-9
(3-12)
1
Myself
Children
Medicare
Do
not
want
Conditions of Enrollment (continued)
Spouse/Domestic Partner
Individual coverage
Other
3. I understand and agree that this Enrollment/Change Form may be transmitted to Aetna or its agent by my employer or its agent. I
have been given
the right to apply
for thistocoverage,
authorize any physician, other healthcare professional, hospital or any otherI acknowledge
healthcare Iorganization
("Providers"),
to give
Aetna however, I am waiving coverage as noted above. By declining this group coverage I
acknowledge
that
myself
and/or
my
dependents
may
have
to
wait
until
the
plan's
next
anniversary
date
to be enrolled for group coverage. Pre-existing conditions,
or its agent information concerning the medical history, services or treatment provided to anyone listed on this Enrollment/Change
when enrolled
other than an
HMO to
plan,
may
not information
be covered for twelve months. NOTE: If your Plan contains a pre-existing conditions provision, the pre-existing
Form, including those involving mental health, substance abuse and HIV/AIDS.
I furtherin authorize
Aetna
use
such
conditions
and limitation does
not apply
to a person under
and to disclose such information to affiliates, Providers, payors, other insurers,
third exclusion
party administrators,
vendors,
consultants
and 19 years of age.
Date (Month/Day/Year)
Please sign
here ONLY
if you are declining
coverage
for yourself or your dependent(s).
governmental authorities with jurisdiction when necessary for my care or treatment,
payment
for services,
the operation
of my
X Employee
Signature
health plan, or to conduct related activities. I have discussed the terms of this
authorization
with my spouse/domestic partner and
competent adult dependents and I have obtained their consent to those terms. This authorization will remain valid for the term of
H. Health Questionnaire for Groups With
Eligible Employees (and employees of groups enrolling for Life coverage greater than the
the coverage and so long thereafter as allowed by law, which in no event shall be for more than twenty-four (24) months. I
Guaranteed Issue Level)
understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid as the original. I
Employees
and your
Dependents.
understand that I may revoke this authorization by calling Member ServicesHealth
usingHistory
the toll for
free
number listed
on my
Member The following information is confidential and will not be seen by or given to your employer.
Social Security Number
5
2 - 50
4.
5.
6.
7.
• ALL of the questions
be answered
by you andand
your dependents or the enrollment form will be returned.
Identification Card. Upon receipt of my request, I will be sent a Revocation of Authorization
form bymust
Aetna
to be completed
• Incomplete enrollment
forms
may delayof
theauthorization.
effective date of your coverage.
returned to Aetna. Aetna will accept a form developed by my employer or my hand-written
request for
revocation
Listthat
all individuals
enrolling
for coverage.
However, the employer form or my request must include all the data elements
are included
in Aetna’s
standard revocation
form.
Sex
Age
Height
Name
The plan documents will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any
benefits comparison, summary or other description of the plan.
I understand and agree that, with the exception of Aetna Rx Home Delivery®, all participating providers and vendors are
independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna
Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change. Notice
of the change shall be provided in accordance with applicable state law.
I understand and agree that, with certain exceptions described in the plan documents, HMO plans only provide coverage for
referred benefits, and that, in order to be covered, services must be performed either by a participating primary care physician or by
2
the participating specialist, hospital, pharmacy, dentist, or other provider asGR-68753-9
authorized(3-12)
by a referral from a participating primary
care physician.
I understand and agree that, as described in the plan documents, when enrolled for medical coverage in other than an HMO plan,
any pre-existing conditions for my spouse/domestic partner, dependents or myself may not be covered for 12 months. NOTE: If
your Plan contains a pre-existing conditions provision, the pre-existing conditions exclusion and limitation does not apply to a
person under 19 years of age.
Misrepresentation
8. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Even if this application is approved, I understand that Aetna cannot rescind my coverage based on my health, however, coverage
can be rescinded or reevaluated, as of the effective date, for eligibility and rating purposes, due to my misrepresentation, fraudulent
statements, or omission of information regarding my health.
I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions of Enrollment and
Misrepresentation on this Oklahoma (2-100 Eligible Employees) Employee Enrollment/Change Form. I understand that, in the event I
fail to sign this form within 31 days after the above transaction request or for any 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. I am employed by
the employer shown on Page 1, and I am working full time at least 24 hours per week for this employer at the regular place of business.
6
24
Employee Signature
X
Employee E-mail Address (optional) Date (Month/Day/Year)
Weight
Currently Taking
Prescription
Medication(s)
Cigarette
Smoker
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
continued on next page
OK
OK
R-POD
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 identifies you as
an Aetna member.
Plan in which you are enrolled.
Call this number to speak
with a Member Services
representative.
Additional information,
including precertification
number for mental health and
substance abuse services.
25
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/dental services. If you are in a plan that requires the selection of a primary care
physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to
specialists and hospitals that are affiliated with the delivery system or physician group. Health/dental benefits and health/dental insurance plans contain
exclusions and limitations.
Discount programs provide access to discounted prices and are NOT insured benefits. 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. RelayHealth is not affiliated with Aetna and Aetna is not responsible for the actions of RelayHealth.
Not all health/dental services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan
features and availability may vary by location and are subject to change. Health/dental information programs provide general health information and are not a
substitute for diagnosis or treatment by a physician or other health care professional.
HealthEquity, Inc. is the custodian of health saving accounts and independently offers investment services.
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 licensed pharmacy subsidiary of Aetna
Inc. that operates through mail order. 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.
Policy forms issued in OK include: HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-9/GR-9N, GR-23 and/or GR-29/GR-29N.
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
©2012 Aetna Inc.
14.02.965.1-OK E (6/12)
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