Aetna Health Of Utah Inc. Dba Altius Health Plan


Aetna Health of Utah Inc. dba Altius Health Health Maintenance Organization (High and Standard) Options and aHigh Deductible Health Plan (HDHP) Option.This plan’s health coverage qualifies as minimum essential coverageand meets the minimum value standard for the benefits it provides. Seepage 9 for details. This Plan is accredited. See page 14.IMPORTANT Rates: Back Cover Changes for 2021: Page 21 Summary of Benefits: Page 158Serving: Utah, Idaho and WyomingEnrollment in this plan is limited. You must live or work in ourgeographic service area to enroll. See page 20 for requirements.Enrollment codes for this Plan:9K1 High Option - Self Only9K3 High Option - Self Plus One9K2 High Option - Self and FamilyDK4 Standard Option - Self OnlyDK6 Standard Option - Self Plus OneDK5 Standard Option - Self and Family9K4 HDHP Option - Self Only9K6 HDHP Option - Self Plus One9K5 HDHP Option - Self and FamilyRI 73-564

Important Notice from Altius Health Plans About Our Prescription Drug Coverage and MedicareThe Office of Personnel Management (OPM) has determined that the Altius Health Plans’ prescription drug coverage is, onaverage, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participantsand is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra forprescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for lateenrollment as long as you keep your FEHB coverage.However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and Altius Health Plans willcoordinate benefits with Medicare.Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.Please be advisedIf you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s at least as goodas Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for everymonth that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drugcoverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay thishigher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the nextAnnual Coordinated Election Period October 15 through December 7 to enroll in Medicare Part D.Medicare’s Low Income BenefitsFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.Information regarding this program is available through the Social Security Administration (SSA) online at, or call the SSA at 800-772-1213 (TTY: 800-325-0778).You can get more information about Medicare prescription drug plans and the coverage offered in your area from theseplaces: Visit for personalized help. Call 800-MEDICARE (800-633-4227), (TTY: 877-486-2048).

Table of ContentsImportant Notice .1Table of Contents .1Introduction .4Plain Language .4Stop Health Care Fraud! .4Discrimination is Against the Law .6Preventing Medical Mistakes .6FEHB Facts .9Coverage information .9 No pre-existing condition limitation.9 Minimum essential coverage (MEC) .9 Minimum value standard (MVS) .9 Where you can get information about enrolling in the FEHB Program .9 Types of coverage available for you and your family .9 Family member coverage .10 Children’s Equity Act .11 When benefits and premiums start.11 When you retire .12When you lose benefits .12 When FEHB coverage ends .12 Upon divorce .12 Temporary Continuation of Coverage (TCC) .12 Finding replacement coverage .13 Health Insurance Marketplace .13Section 1. How This Plan Works .14General features of our High and Standard Options .14We have Open Access benefits .15How we pay providers .15General features of our High Deductible Health Plan (HDHP) .15Your rights and responsibilities .17Your medical and claims records are confidential .17Service Area .20Section 2. Changes for 2021 .21Changes to High Option only.21Changes to the Standard Option only .21Changes to the High Deductible Health Plan only .21Changes to the High Option, Standard Option and High Deductible Health Plan (HDHP) Option .21Section 3. How You Get Care .22Identification cards .22Where you get covered care .22 Plan providers .22 Plan facilities .22What you must do to get covered care .22 Primary care .22 Specialty care .23 Hospital care .232021 Aetna Health of Utah Inc. dba Altius Health Plan1Table of Contents

If you are hospitalized when your enrollment begins.23You need prior Plan approval for certain services .23 Inpatient hospital admission .24 Other services .24How to request precertification for an admission or get prior authorization for Other services .25 Non-urgent care claims .26 Urgent care claims .26 Concurrent care claims .26 Emergency inpatient admission .26 Maternity care .27 If your treatment needs to be extended .27 Circumstances beyond our control .27 If you disagree with our pre-service claim decision .27 To reconsider a non-urgent care claim .27 To reconsider an urgent care claim .27 To file an appeal with OPM .27Section 4. Your Costs for Covered Services .29Cost-sharing .29Copayments .29Deductible .29Coinsurance .29Differences between our Plan allowance and the bill .30Your catastrophic protection out-of-pocket maximum .30Carryover .31When Government facilities bill us .31Section 5. High and Standard Option Benefits .32Section 5. High Deductible Health Plan Benefits .77Non-FEHB Benefits Available to Plan Members.136Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover .137Section 7. Filing a Claim for Covered Services .138Medical, hospital and prescription drug benefits .138Deadline for filing your claim .138Post-service claims procedures .138Authorized Representative .139Notice Requirements .139Section 8. The Disputed Claims Process.140Section 9. Coordinating Benefits with Medicare and Other Coverage .143When you have other health coverage .143 TRICARE and CHAMPVA .143 Workers’ Compensation .143 Medicaid .143When other Government agencies are responsible for your care .144When others are responsible for injuries.144When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage .144Clinical Trials .145When you have Medicare .145 The Original Medicare Plan (Part A or Part B) .146 Tell us about your Medicare coverage .146 Medicare Advantage (Part C) .1472021 Aetna Health of Utah Inc. dba Altius Health Plan2Table of Contents

Medicare prescription drug coverage (Part D) .147Section 10. Definitions of Terms We Use in This Brochure .149Index.154Summary of Benefits for the High Option of Altius Health Plans - 2021 .158Summary of Benefits for the Standard Option of Altius Health Plans - 2021 .159Summary of Benefits for the High Deductible Health Plan (HDHP) of Altius Health Plans - 2021 .1602021 Rate Information

Health Insurance Marketplace . How we pay providers . Utah Inc. dba Altius Health Plan under Aetna contract (CS 2839) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Custo