2024 Plan Coverage Documents

Review these plan documents for a detailed explanation of coverage. Contact the plan administrator with coverage questions.

Medical

All enrollees

• Aetna Member Notice

Aetna Medicare Plan

All enrollees

• Access2Care Transportation Benefit

PPO enrollees

• Annual Notice of Changes (Medicare Parts A & B)
• Evidence of Coverage (Medicare Parts A & B)
• Schedule of Cost Sharing (Medicare Parts A & B)

• Annual Notice of Changes (Medicare Part B-Only)
• Evidence of Coverage (Medicare Part B-Only)
• Schedule of Cost Sharing (Medicare Part B-Only)

ESA PPO enrollees

• Annual Notice of Changes (Medicare Parts A & B)
• Evidence of Coverage (Medicare Parts A & B)
• Schedule of Cost Sharing (Medicare Parts A & B)

• Annual Notice of Changes (Medicare Part B-Only)
• Evidence of Coverage (Medicare Part B-Only)
• Schedule of Cost Sharing (Medicare Part B-Only)

Aetna Basic Plan

• Medical Plan Description
• PPO Schedule of Benefits
• Indemnity Schedule of Benefits
• PPO Summary of Benefits and Coverage
• Indemnity Summary of Benefits and Coverage
• Transform Oncology Program
• Required Notice for the Women’s Health and Cancer Rights Act of 1998

Aetna Basic Health Care Assistance Plan (HCAP)

• PPO Schedule of Benefits
• Indemnity Schedule of Benefits
• PPO Summary of Benefits and Coverage
• Indemnity Summary of Benefits and Coverage

Prescription

All enrollees

• Low-Cost Generic Drug List
• Mail Service Order Form

SilverScript (Medicare enrollees)

• Evidence of Coverage
• Formulary
• Summary of Benefits
• Notice of Medicare Part D Creditable Coverage

CVS Caremark (non-Medicare enrollees)

• Prescription Medication Plan Description
• Formulary
• Advanced Control Specialty Formulary

Dental and vision

Delta Dental

• Summary of Dental Plan Benefits
• Certificate of Coverage
• Special Health Care Needs Benefit

Vision Service Plan (VSP)

• Evidence of Coverage
• Special Offers on Glasses, Contacts, LASIK & More