Aetna Open Access Plan 2021 Federal Employees Health Benefits (FEHB) Coverage

Plan Overview

The Aetna Open Access Plan (OAP) is one of the most popular options within the Federal Employees Health Benefits (FEHB) program for the 2021 plan year. It is a openaccess plan, meaning members can receive care from any provider that accepts Aetnas commercial insurance contracts, without needing a primary care physician (PCP) referral to see specialists. The plan is designed to offer comprehensive coverage while giving federal employees the flexibility to choose innetwork or outofnetwork providers.

Eligibility & Enrollment

All federal civilian employees, retirees, and their eligible family members may enroll in the Aetna OAP, provided they are eligible for FEHB coverage. Enrollment periods include:

• Annual Open Season (October1December15): The primary window for new enrollment or changes.
• Qualifying Life Events (QLEs): Marriage, birth or adoption, loss of other coverage, etc., allow a special enrollment within 60 days of the event.

Employees who are already covered by another FEHB plan may switch to Aetna OAP during Open Season without penalty.

Medical Benefits

The 2021 Aetna OAP provides the following core medical benefits:

• Inpatient hospital care (room & board, surgery, ICU).
• Outpatient services, including primary care, specialist visits, and urgent care.
• Maternity care, newborn care, and family planning.
• Emergency services coverage regardless of network status.
• Behavioral health services (psychotherapy, psychiatry, substanceuse treatment).
• Rehabilitative services (physical, occupational, speech therapy).
• Home health care and hospice services.

Coverage Levels

The plan is offered in three benefit tiersStandard, High, and UltraHigh. Each tier differs primarily in outofpocket maximums and coinsurance percentages. For example, the Standard tier carries a $5,000 individual outofpocket limit, whereas the UltraHigh tier raises the limit to $10,000 but reduces coinsurance for many services.

Prescription Drug Coverage

The Aetna OAP includes a robust prescription drug benefit that is integrated with the medical plan. Key features include:

• Tiered formulary: Tier1 (generics), Tier2 (preferred brand), Tier3 (nonpreferred brand), Tier4 (specialty drugs).
• Preferred pharmacy network offering lower copayments.
• Mailorder option for 90day suppliesgenerally cheaper than retail.
• Coverage for most FDAapproved drugs, with a few exceptions listed in the formulary exclusions.

Dental & Vision Options

While the core Aetna OAP does not include dental or vision, members can add separate Aetna dental and vision plans through the FEHB marketplace. These supplemental plans offer:

• Preventive dental services (cleanings, exams, Xrays) at 100%.
• Major restorative work (crowns, bridges) with a 2030% coinsurance.
• Vision coverage for exams, lenses, frames, and contacts.

Cost Sharing & Premiums

Premiums are based on the employees pay grade, location, and selected benefit tier. For the 2021 plan year, average monthly premiums were:

• Standard tier: $289 (employee only), $860 (family).
• High tier: $322 (employee only), $950 (family).
• UltraHigh tier: $357 (employee only), $1,040 (family).

Costsharing details:

• Innetwork primary care visit: $25 copay.
• Innetwork specialist visit: $40 copay.
• Emergency room (innetwork): $125 copay or 20% of the allowed amount, whichever is less.
• Generic prescription: $10 copay (preferred pharmacy).
• Specialty drug: 30% coinsurance after deductible.

Provider Networks

The Aetna OAP utilizes a blended network model:

• Participating Provider Network (PPN): Preferred rates, lower costsharing.
• OutofNetwork (OON): Services are covered but at higher coinsurance and a separate deductible.

Members are encouraged to use the Aetna Provider Finder to locate innetwork physicians, hospitals, and pharmacies.

Special Programs & Preventive Care

Preventive services are covered at 100% when provided by an innetwork provider, with no deductible required. This includes:

• Annual physicals, wellchild visits, and immunizations.
• Screenings for cancer, diabetes, cholesterol, and hypertension.
• Smoking cessation programs and weightmanagement counseling.

The plan also offers a Telehealth Service via the Aetna Health app, allowing virtual visits for minor illnesses, mentalhealth consultations, and followup appointments.

How to File a Claim

Most innetwork services are billed directly to Aetna, so members receive a single statement for any remaining balance. For outofnetwork services, the member must submit a claim:

1. Obtain a completed claim form (available online or from customer service).
2. Attach itemized receipts and an Explanation of Benefits (EOB) if provided.
3. Submit electronically through the Aetna portal or mail to the address on the form.
4. Claims are processed within 1530 business days; status can be checked online.

Appeals & Grievances

If a claim is denied or a coverage decision is unfavorable, members may:

• File an internal appeal with Aetna within 180 days of the denial.
• Request an external review by an independent reviewer if the internal appeal is denied.
• Contact the Office of the Assistant Secretary for Employee Benefits (OAS) for unresolved grievances.

All appeal instructions and contact information are included in the members EOB and on the Aetna website.

Helpful Resources

• Official FEHB website enrollment dates, plan comparison tools.
• Aetna Open Access Plan 2021 Summary of Benefits.
• Aetna Telehealth Services.
• Customer Service: 18005551234 (available 24/7).
• Member portal: myaccount.aetna.com view claims, find providers, manage prescriptions.