Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
The member's benefit plan determines coverage. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member.
Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. List of all medications that are covered at 100% on all formularies.By clicking on “I Accept”, I acknowledge and accept that:
Tetanus-Diphtheria/Tetanus-Diphtheria Acellular Pertussis (Tdap). See your doctor and refer to the CDC’s posted schedule of immunizations for more information. Doses, recommended ages and recommended populations vary. The following are the recommended vaccines for men that are covered with no out of pocket cost. More information: Preventive care includes 4 treatments provided by a physician and 30 nutritional counseling visits by a licensed dietician or nutritionist. Frequency: May vary based on your health so ask your doctor. Description: If your body mass index (BMI) is 30 or higher, your doctor should refer you to or offer you intensive, multi-component behavioral interventions. Barium enema is a covered service but not at 100% so you may have out of pocket costs. If there is a medical reason you cannot use a generic bowel preparation medication, your doctor should review this ACA Copay Waiver Criteria if you meet these criteria, they can submit this information on this fax form. Certain bowel preparation medications for a screening colonoscopy are covered at 100% when prescribed by a doctor. Provider consultation prior to the colonoscopy procedure is covered at 100%. Anesthesia and pathology from polyps found during a screening colonoscopy is covered at 100%. This colonoscopy will be covered but may not be considered preventive so you may have out of pocket costs. Your doctor may order a colonoscopy more frequently than every 10 years. If you had a polyps removed during a previous preventive screening colonoscopy, future colonoscopies will be covered but may not be considered preventive so you may have out of pocket costs. Starting June 1, 2022, this follow up colonoscopy will be covered at 100%. If you have a positive fecal blood test (gFOBT or FIT or Cologuard), or visualization test (CT colonography or sigmoidoscopy), your doctor may order a follow up colonoscopy. Frequency: Using fecal blood testing (gFOBT or FIT) annually, Cologuard every 3 years, sigmoidoscopy or CT/virtual colonography every 5 years, or colonoscopy every 10 years. * Effective no later than April 1, 2022, colorectal cancer screening and associated services are covered at 100% for eligible members aged 45 and older. Description: Screening for colon/colorectal cancer in adults age 45–75. Non-Discrimination Policy and Accessibility Services. Get a Quote for Individual and Family PlansĪncillary and Specialty Benefits for Employees. Health Plans for Individuals and Families.
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