This plan covers medically necessary acupuncture for adults for any of the following conditions:

Contact Aetna or Kaiser for details and restrictions.

The plan covers services and supplies for the diagnosis and treatment of Autism Spectrum Disorders prescribed by a physician or other behavioral health provider with no annual maximum such as Applied Behavior Analysis (ABA). ABA is an educational service that is the process of applying intensive behavioral interventions:

The plan provides coverage for bariatric surgery (including procedures to adjust or reverse bariatric surgery). Bariatric surgery, or weight loss surgery, is surgery to reduce the size of the stomach through any of the following:

Coverage for bariatric surgery is based upon specific criteria outlined in Aetna's or Kaiser's Coverage Policy for Bariatric Surgery. Contact Aetna or Kaiser for details and restrictions prior to receiving services.

The Plan does not cover bariatric surgery procedures that are not considered medically necessary, or that are deemed experimental, investigational or unproven. Please contact Aetna or Kaiser for details. Some excluded procedures include (but are not limited to):

Charges made for diagnostic and treatment services used in an office setting by chiropractic physicians. Chiropractic treatment includes the conservative management of acute neuromusculoskeletal conditions through manipulation and ancillary physiological treatment of specific joints to restore motion, reduce pain and improve function.

The plan provides benefits for routine patient care as the result of a phase II, III and IV clinical trial for the purposes of prevention, early detection or treatment of cancer, if approved by one of the following entities, and the treating facility and personnel have the expertise and training to provide the treatment and treat a sufficient number of patients:

Routine patient care costs are defined as follows:

The plan covers participation in Clinical Trials as described above at all Commission on Cancer-approved facilities and cancer centers designated by the NCI.

The plan provides coverage for:

Diagnostic procedures help your physician find the cause and extent of your condition in order to plan for your care. Benefits may differ depending on where the service is performed and if the service is received with any other service or associated with a surgical procedure.

Separate benefits for the interpretation of diagnostic services by the attending doctor are not provided. In addition, benefits for that doctor's medical or surgical services are not included, except as otherwise determined by Aetna or Kaiser, as applicable.

Benefits are provided for durable medical equipment and supplies required for operation of equipment when prescribed by a doctor. Equipment may be purchased or rented at the discretion of the plan. The plan provides benefits for repair or replacement of the covered equipment. Benefits will end when the equipment is no longer medically necessary. Certain durable medical equipment requires pre-certification or services will not be covered.

Examples of covered durable medical equipment include:

Benefits are provided for family planning including physical exams, related laboratory tests, medical supervision in accordance with generally accepted medical practices and other medical services.

Contraception devices (e.g., Depo-Provera and Intrauterine Devices (IUDs)) and diaphragms are covered at 100% as mandated by the Patient Protection and Affordable Care Act (PPACA).

Sterilization includes female tubal ligation and male vasectomy.

Covered services include:

For individuals seeking care for gender dysphoria, a variety of therapeutic options can be considered. The number and type of interventions applied and the order in which these take place may differ from person to person. IQVIA follows the recommendations of the World Professional Association for Transgender Health, treatment options include the following:

Benefits are provided for genetic testing that uses a proven testing method for the identification of genetically-linked inheritable disease.

Coverage for genetic testing is based upon specific criteria outlined in Aetna's or Kaiser's Coverage Policy for Genetic Testing. Contact Aetna or Kaiser for details and restrictions prior to receiving services.

Hearing aids are covered at the applicable coinsurance after the deductible up to a $1,000 benefit maximum per ear once per calendar year.

Home health care services are covered by the plan if you require skilled care, cannot obtain the required care as an ambulatory outpatient and do not require inpatient treatment at a hospital or other health care facility.

Home health care, including nursing and home infusion, requires pre-certification or services will not be covered. Coverage for home health care expenses is limited to a combined in- and out-of-network maximum of 120 visits per calendar year.

Benefits will be provided for:

Your coverage provides benefits for hospice services for care of a terminally ill covered individual with a life expectancy of six months or fewer. Hospice services are covered only as part of a licensed health care program that provides an integrated set of services and supplies designed to give comfort, pain relief and support to terminally ill patients and their families. A hospice care program is centrally coordinated through an interdisciplinary team directed by a doctor.

Covered services include:

Laboratory studies are services such as diagnostic blood, urine tests or an examination of biopsied tissue (i.e., tissue removed from your body by a surgical procedure). Radiology services are diagnostic imaging procedures such as X-rays, ultrasounds, computed tomographic (CT) scans and magnetic resonance imaging (MRI) scans.

Other diagnostic testing includes electroencephalograms (EEGs), electrocardiograms (ECGs), Doppler scans and pulmonary function tests (PFTs). Certain diagnostic imaging procedures, such as CT scans and MRIs, require Pre-certification or services will not be covered.

The plan provides benefits for transplants, including solid organ and bone marrow/stem cell procedures for the transplants listed below. Covered services include medical, surgical and hospital services, medications and the cost for organ or bone marrow/stem cell procurement.

Transplant services are covered at 80% in the $400, $900 and $1,850 Deductible Plans and 70% in the $2,850 Deductible Plan, after the medical plan deductible if you use a Center of Excellence. Services are covered at 60% in the $400, $900 and $1,850 Deductibles Plans and 50% in the $2,850 Deductible Plan, after the medical plan deductible if you use a non-Center of Excellence.

Benefits are also provided for reasonable travel expenses when a covered member travels a distance of 100 miles or greater for a pre-approved organ/tissue transplant (excluding cornea) performed at a Center of Excellence. A maximum travel benefit of $10,000 per transplant per lifetime is provided. Coverage varies by the plan. Lodging is covered up to $50 per day for one person staying alone or up to $100 per day for two people. Food and meals are not covered.

Pre-certification must be obtained in advance from Aetna or Kaiser for all transplant related services or your benefits may be reduced or denied.

If you are traveling overseas for a short-term visit (non-Expat), your Aetna or Kaiser plan will provide emergency coverage, it will not cover routine care.

If you are an eligible Expat, you will be covered under the Aetna International Plan. Coverage is provided for in-network and out-of–network care, as well as for care received outside of the U.S. While no annual deductible applies outside of the U.S., there is an out-of-network deductible inside the U.S. There is also an out-of-pocket maximum for in-network and out-of-network services received in the U.S. Coverage for Expats under the Aetna International Plan differs from coverage provided under the plans described in this SPD. Contact your benefits representative for details.

The plan provides benefits for the initial purchase and fitting of medically necessary external prosthetic appliances and devices prescribed by a doctor. Coverage is limited to the most appropriate and cost effective alternatives as determined by the utilization review physician. External prosthetic appliances and devices include prostheses/prosthetic appliances and devices, orthoses/orthotic devices (including custom foot and other orthoses), braces and splints.

The plan provides benefits for internal prosthetic/medical appliances that provide permanent or temporary internal functional support for non-functional body parts. Medically necessary repair, maintenance or replacement of a covered appliance is also covered.

Reconstructive surgery or therapy to repair or correct a severe physical deformity or disfigurement which is accompanied by functional deficit (other than abnormalities of the jaw or conditions related to TMJ disorder) is covered if:

The plan provides coverage for the following therapy services to promote the recovery from an illness, disease or injury. A doctor or other professional provider must order these services.

Short-term rehabilitative therapy that is part of a rehabilitation program, including physical, speech, occupational, cognitive, cardiac therapy, osteopathic manipulative and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting.

In network therapy, days are provided as part of an approved home health care plan and accumulate to the short-term rehabilitative therapy maximum. If multiple outpatient services are provided on the same day, the services count as having been received on one day.

Short-term rehabilitative therapy services that are not covered include, but are not limited to:

The IQVIA Plan includes coverage for telephone and online video consultations through Teladoc offered through Aetna. Teladoc connects you to a board-certified doctor by phone or online video chat 24 hours a day, seven days a week, 365 days a year. Teladoc doctors can treat many non-emergency conditions such as:

You must register for the service either online at Teladoc.com/Aetna or call 855-Teladoc (835-2362).