OMB Approval 0938-1051 (Expires: February 29, 2024)
GRP_ANOC_2024_L6_31796-5_34827-3
Master Plan ID: 0000520, 0015110
State Teachers Retirement System of Ohio
Get ready for 2024
The Centers for Medicare & Medicaid Services (CMS) requires us to notify you of an administrative change
to your Aetna Medicare Advantage PPO plan effective January 1, 2024. STRS Ohio’s current Aetna
Medicare Plan is offered under CMS contract H5521 and will be changing to H5522. This change is
administrative only and will not impact your coverage, plan programs or provider network. However, you
will receive a new ID card. No action is needed to remain enrolled in STRS Ohio’s Aetna Medicare Plan
for 2024.
Note: The information below about being enrolled in another Aetna Medicare Plan applies to this
contract change only. You will still be covered by STRS Ohio’s Aetna Medicare Plan in 2024.
We are enrolling you in another Aetna Medicare Plan as your retiree health benefit plan beginning January
1, 2024, unless you tell us by December 31, 2023 that you don’t want to remain covered by Aetna Medicare
and be in your retiree plan. The Aetna Medicare Plan is a Medicare Advantage plan. You will be
automatically enrolled into your new plan and this enrollment will automatically cancel your enrollment in
the previous Aetna Medicare Advantage plan. Please call us at the number on your ID card if you think you
might be enrolled in a different Medicare Advantage plan or a Medicare prescription drug plan.
Again, you don’t need to take any action if you would like to continue your current coverage.
Look for your new member ID card
We’ll mail it closer to the end of the year. You can start using it January 1, 2024. (Be sure to share it with
your doctor, hospital and pharmacy, too.) Until then, keep using your current member ID card.
What do I need to know as a member of the Aetna Medicare Plan?
This mailing includes important information about this plan and the coverage it offers, including
information on how to access a Summary of Benefits document. Please review this information carefully.
To be enrolled in this Medicare health plan, you don’t have to do anything, and your enrollment for 2024
will automatically begin on January 1, 2024.
As a member of the Aetna Medicare Plan, you have the right to appeal plan decisions about payment or
services if you disagree.
Be sure to review your 2024 Evidence of Coverage, too. You can access it online. The enclosed Plan
Document Notice tells you how. Your Evidence of Coverage will help you to understand which rules you
must follow to get coverage with this Medicare Advantage Plan. Enrollment in this plan is generally for the
entire year.
You can only be in one Medicare Advantage plan at a time.
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2 Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024
By joining this Medicare health plan, you acknowledge that the Medicare health plan will release your
information to Medicare and other plans as is necessary for treatment, payment and health care
operations. You also acknowledge that the Medicare health plan will release your information to Medicare,
who may release it for research and other purposes which follow all applicable Federal statutes and
regulations.
What happens if I don’t want to continue my Aetna Medicare coverage in 2024?
You aren’t required to be enrolled in this plan. You can decide to join a different Medicare plan. If you
would like to discuss your options, please call the STRS Service Center at 1‑888‑227‑7877. You can also
call 1‑800‑MEDICARE anytime, 24 hours a day, 7 days a week for more information. To request to not be
enrolled by this process, call your dedicated Aetna Member Services Center at 1‑833‑383‑4612 which is
available Monday‑Friday, 8 AM‑9 PM ET.
Remember that if you leave this plan and don’t have creditable prescription drug coverage (as good as
Medicare’s prescription drug coverage), you may have to pay a late enrollment penalty if you enroll in
Medicare prescription drug coverage in the future.
For any questions about this letter, please call the number on your ID card.
Thank you.
See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by service area.
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Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024 3
Aetna Medicare Plan (PPO) offered by Aetna Medicare
Annual Notice of Changes for 2024
You are currently enrolled as a member of Aetna Medicare Plan (PPO). Next year, there will be some
changes to the plan’s costs and benefits. Please see page 6 for a Summary of Important Costs, including
Premium.
This document tells about the changes to your plan. To get more information about costs, benefits, or
rules please review the Evidence of Coverage and the Schedule of Cost Sharing, which is located on our
website at STRS.AetnaMedicare.com. You may also call Member Services to ask us to mail you an
Evidence of Coverage and/or Schedule of Cost Sharing.
What to do now
1. ASK: Which changes apply to you
£
Check the changes to our benefits and costs to see if they affect you.
Review the changes to Medical care costs (doctor, hospital).•
Think about how much you will spend on premiums, deductibles, and cost sharing.•
£
Check to see if your primary care doctors, specialists, hospitals, and other providers will be in our
network next year.
£
Think about whether you are happy with our plan.
2. COMPARE: Learn about other plan choices – Your coverage is offered through State Teachers
Retirement System of Ohio (STRS Ohio)
It is important that you carefully consider your decision before changing your STRS
Ohio coverage. If you disenroll from this Aetna Medicare Advantage plan, to join
another Medicare Advantage plan, then your STRS Ohio plan benefits may be
cancelled. Please contact STRS Ohio before you make a plan change.
£
Contact STRS Ohio to see if there are other options available.
£
Check coverage and costs of plans in your area. Use the Medicare Plan Finder at
www.medicare.gov/plan-compare website or review the list in the back of your Medicare & You
2024 handbook.
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4 Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024
3. CHOOSE: Decide whether you want to change your plan
If you want to keep the same Aetna Medicare plan, STRS Ohio will give you instructions if there is
any action you need to take to remain enrolled.
•
You can change your coverage during STRS Ohioopen enrollment period. STRS Ohio will tell you
what other plan choices might be available to you under your group retiree coverage.
•
You can switch to an individual Medicare health plan or to Original Medicare; however, this would
mean dropping your group retiree coverage. As a member of a group Medicare plan, you are
eligible for a special enrollment period if you leave STRS Ohioplan. This means that you can enroll
in an individual Medicare health plan or Original Medicare at any time.
•
Additional Resources
This document is available for free in Spanish. Este documento está disponible sin cargo en español.•
Please contact our Member Services at the telephone number on your member ID card or call our
general Member Services at 1‑833‑383‑4612 for additional information. (TTY users should call 711.)
Hours are 8 AM to 9 PM ET, Monday through Friday. This call is free.
•
This document may be available in other formats such as braille, large print or other alternate
formats. Please contact Member Services for more information.
•
Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient
Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit
the Internal Revenue Service (IRS) website at www.irs.gov/Affordable-Care-Act/Individuals-and-
Families for more information.
•
About Aetna Medicare Plan (PPO)
Aetna Medicare is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on
contract renewal.
•
When this document says “we,” “us,” or “our,” it means Aetna Medicare. When it says “plan” or “our
plan,” it means Aetna Medicare Plan (PPO).
•
Y0001_ANOC24_M
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Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024 5
Annual Notice of Changes for 2024
Table of Contents
Summary of Important Costs for 2024 6
SECTION 1 Changes to Benefits and Costs for Next Year
7
Section 1.1 Changes to the Monthly Premium
7
Section 1.2 Changes to Your Maximum Out‑of‑Pocket Amount
7
Section 1.3 Changes to the Provider Network
7
Section 1.4 Changes to Benefits and Costs for Medical Services
8
SECTION 2 Administrative Changes
9
SECTION 3 Deciding Which Plan to Choose
10
Section 3.1 If you want to stay in Aetna Medicare Plan (PPO)
10
Section 3.2 If you want to change plans
10
SECTION 4 Deadline for Changing Plans
10
SECTION 5 Programs That Offer Free Counseling about Medicare
11
SECTION 6 Programs That Help Pay for Prescription Drugs
11
SECTION 7 Questions?
12
Section 7.1 Getting Help from Aetna Medicare Plan (PPO)
12
Section 7.2 Getting Help from Medicare
12
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6 Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024
Summary of Important Costs for 2024
The table below compares the 2023 costs and 2024 costs for Aetna Medicare Plan (PPO) in several
important areas. Please note this is only a summary of costs.
Cost
2023 (this year) 2024 (next year)
Deductible In‑network:
$150
Combined in‑network and
out‑of‑network deductible:
$500
In‑network:
No Deductible
Combined in‑network and
out‑of‑network deductible:
$500 except for insulin
furnished through an item of
durable medical equipment.
Maximum out‑of‑pocket amount
This is themost you will pay
out‑of‑pocket for your covered services.
(See Section 1.2 for details.)
From network providers:
$1,500
From network and
out‑of‑network providers
combined:
$2,500
From network providers:
$1,500
From network and
out‑of‑network providers
combined:
$2,500
Doctor office visits In‑network:
Primary care visits:
$15 copay per visit.
Specialist visits:
$25 copay per visit.
Out‑of‑network:
Primary care visits:
$40 copay per visit.
Specialist visits:
$55 copay per visit.
In‑network:
Primary care visits:
$0 copay per visit.
Specialist visits:
$25 copay per visit.
Out‑of‑network:
Primary care visits:
$40 copay per visit.
Specialist visits:
$55 copay per visit.
Inpatient hospital stays
Includes inpatient acute, inpatient
rehabilitation, long‑term care hospitals,
and other types of inpatient hospital
services. Inpatient hospital care starts
the day you are formally admitted to the
hospital with a doctor’s order. The day
before you are discharged is your last
inpatient day.
In‑network:
4% per stay
Out‑of‑network:
8% per stay
In‑network:
4% per stay
Out‑of‑network:
8% per stay
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Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024 7
SECTION 1 Changes to Benefits and Costs for Next Year
Section 1.1 Changes to the Monthly Premium
Your coverage is provided through a contract with STRS Ohio.STRS Ohiowill provide you with information
about your plan premium (if applicable).
You must also continue to pay your Medicare Part B premium.
Section 1.2 Changes to Your Maximum Out‑of‑Pocket Amount
Medicare requires all health plans to limit how much you pay out‑of‑pocket during the year. These limits
are called the maximum out‑of‑pocket amounts. Once you reach this amount, you generally pay nothing
for covered services for the rest of the year.
Cost
2023 (this year) 2024 (next year)
In‑network maximum out‑of‑pocket
amount
Your costs for covered medical services
(such as copays and deductibles, if
applicable) from network providers
count toward your maximum
out‑of‑pocket amount. Your plan
premium (if applicable) does not count
toward your maximum out‑of‑pocket
amount.
$1,500 $1,500
Once you have paid $1,500
out‑of‑pocket for covered
services, you will pay nothing
for your covered services
from network providers for
the rest of the calendar year.
Combined maximum out‑of‑pocket
amount
Your costs for covered medical services
(such as copays and deductibles, if
applicable) from in‑network and
out‑of‑network providers count toward
your combined maximum out‑of‑pocket
amount. Your plan premium (if
applicable) does not count toward your
maximum out‑of‑pocket amount.
$2,500 $2,500
Once you have paid $2,500
out‑of‑pocket for covered
services, you will pay nothing
for your covered services
from in‑network or
out‑of‑network providers for
the rest of the calendar year.
Section 1.3 Changes to the Provider Network
Updated directories are located on our website at STRS.AetnaMedicare.com. You may also call Member
Services for updated providerinformation or to ask us to mail you aProvider Directory, which we will mail
within three business days.
There are changes to our network of providers for next year. Please review the 2024 Provider Directory
to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
It is important that you know that we may make changes to the hospitals, doctors, and specialists
(providers) that are part of your plan during the year. If a mid‑year change in our providers affects you,
OMB Approval 0938-1051 (Expires: February 29, 2024)
8 Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024
please contact Member Services so we may assist.
Section 1.4 Changes to Benefits and Costs for Medical Services
We are making changes to costs and benefits for certain medical services next year. The information
below describes these changes.
Cost
2023 (this year) 2024 (next year)
The annual deductible does not
apply to the following services
The in‑network deductible does
not apply to the following
services: Preventive services,
Part B drugs, Continuous Glucose
Monitors (CGM), diabetic
supplies, diabetic eye exam,
additional Medicare‑covered
preventive services, emergency
room visits, emergency
ambulance, urgent care, renal
care, some Medicare‑covered
diagnostic tests and labs (Urine
protein, Prothrombin testing,
HBA1C, FIT Screening, Fundus
Testing, gFOBT Testing and
COVID lab tests), acupuncture
(office visit only), wigs, MDLive,
lab work and any services where
a copayment is applied,
excluding skilled nursing and
home health services.
No in‑network deductible
Continuous Glucose Monitors Continuous Glucose Monitors
can be obtained at participating
DME providers.
You can get a Dexcom or
FreeStyle Libre brand continuous
glucose monitor and supplies at a
participating pharmacy location
or participating DME provider. If
you choose any other brand, you
can only use a participating DME
provider.
You will need a prescription to
get your monitor and supplies.
Emergency transportation
(worldwide)
Emergency transportation
services (worldwide) are not
covered.
You pay 4% of the total cost for
each service.
Cost sharing is not waived if you
are admitted to the hospital.
Hearing aids Hearing aids are not covered. We will reimburse you up to
$1,000 once every 36 months.
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Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024 9
Cost
2023 (this year) 2024 (next year)
In‑home support services In‑Network:
In‑home support services are not
covered.
In‑Network:
You pay a $0 copay for 6 hours
per discharge when eligible.
Services are provided by The
Helper Bees.
Primary care physician (PCP)
services
In‑Network:
You pay a $15 copay for each
Medicare‑covered service.
In‑Network:
You pay a $0 copay for each
Medicare‑covered service.
Telehealth additional services
— primary care physician (PCP)
In‑Network:
You pay a $15 copay for each
primary care physician service.
In‑Network:
You pay a $0 copay for each
primary care physician service.
The yearly deductible does not
apply to these services
Out‑of‑Network:
The annual combined (plan level)
deductible does not apply to the
following out‑of‑network
services: Preventive services,
additional Medicare covered
preventive services, emergency
room visits, emergency
ambulance, urgent care and
wigs.
Out‑of‑Network:
The annual combined (plan level)
deductible does not apply to the
following out‑of‑network
services: Preventive services,
additional Medicare covered
preventive services, Part B
Insulin, emergency room visits,
emergency ambulance, urgent
care and wigs.
Transportation services
(non‑emergency)
Unlimited ESRD transportation
services are not covered.
If you are diagnosed with ESRD,
you get unlimited trips to covered
medical appointments at $0
copay.
Trips must be within 60
miles of provider location.
•
Wigs You pay 4% of the total cost for
wigs.
Wigs maximum allowance ‑
$300
•
Wigs allowance frequency ‑
every year
•
You pay a $0 copay for wigs.
Wigs maximum allowance ‑
$400
•
Wigs allowance frequency ‑
every year
•
SECTION 2 Administrative Changes
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10 Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024
Description
2023 (this year) 2024 (next year)
Contract change Your plan for 2023 is on CMS
contract H5521.
Your plan for 2024 will be on
CMS contract H5522.
SECTION 3 Deciding Which Plan to Choose
Section 3.1 If you want to stay in Aetna Medicare Plan (PPO)
STRS Ohio will tell you if you need to do anything to stay enrolled in your Aetna Medicare Plan.
Section 3.2 If you want to change plans
We hope to keep you as a member next year but if you want to change plans for 2024 follow these steps:
Step 1:Learn about and compare your choices
You can join a different Medicare health plan. STRS Ohio will let you know what options are available
to you under your group retiree coverage.
•
You can switch to an individual Medicare health plan.•
‑‑OR‑‑ You can change to Original Medicare. If you change to Original Medicare, you will need to
decide whether to join a Medicare drug plan. If you do not enroll in a Medicare drug plan, there may
be a potential Part D late enrollment penalty.
•
It is important that you carefully consider your decision before changing your STRS Ohio coverage. If
you disenroll from this Aetna Medicare Advantage plan, to join another Medicare Advantage plan,
then your STRS Ohio plan benefits may be cancelled. Please contact STRS Ohio before you make a
plan change.
To learn more about Original Medicare and the different types of Medicare plans, use the Medicare Plan
Finder (www.medicare.gov/plan-compare), read the Medicare & You 2024 handbook, call your State
Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2).
Step 2: Change your coverage
To change to a different Medicare health plan, enroll in the new plan. You will automatically be
disenrolled from Aetna Medicare Plan (PPO).
•
Tochange to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will
automatically be disenrolled from Aetna Medicare Plan (PPO).
•
Tochange to Original Medicare without a prescription drug plan,you must either:
Send us a written request to disenroll. Contact Member Services if you need more information
on how to do so.
○
– or –ContactMedicare, at 1‑800‑MEDICARE (1‑800‑633‑4227), 24 hours a day, 7 days a
week, and ask to be disenrolled. TTY users should call 1‑877‑486‑2048.
○
•
SECTION 4 Deadline for Changing Plans
You may be able to change to a different plan during STRS Ohio open enrollment period. Your plan may
allow you to make changes at other times as well. STRS Ohio will let you know what other plan options
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Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024 11
may be available to you.
Are there other times of the year to make a change?
As a member of a group Medicare plan, you are eligible for a special enrollment period if you leave STRS
Ohio plan. This means that you can enroll in an individual Medicare health plan or Original Medicare at any
time during the year.
It is important that you carefully consider your decision before changing your STRS Ohio coverage. If
you disenroll from this Aetna Medicare Advantage plan, to join another Medicare Advantage plan,
then your STRS Ohio plan benefits may be cancelled. Please contact STRS Ohio before you make a
plan change.
SECTION 5 Programs That Offer Free Counseling about Medicare
The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors
in every state.
It is a state program that gets money from the Federal government to give free local health insurance
counseling to people with Medicare. SHIP counselors can help you with your Medicare questions or
problems. They can help you understand your Medicare plan choices and answer questions about
switching plans. You can call SHIP at the phone number in Addendum A at the back of the Evidence of
Coverage.
SECTION 6 Programs That Help Pay for Prescription Drugs
You may qualify for help paying for prescription drugs. Below we list different kinds of help:
“Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay for
their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug
costs including monthly prescription drug premiums, annual deductibles, and coinsurance.
Additionally, those who qualify will not have a coverage gap or late enrollment penalty. To see if you
qualify, call:
1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048, 24 hours a day/7
days a week;
○
The Social Security Office at 1‑800‑772‑1213 between 8 am and 7 pm, Monday through Friday
for a representative. Automated messages are available 24 hours a day. TTY users should call
1‑800‑325‑0778; or
○
Your State Medicaid Office (applications).
○
•
Help from your state's pharmaceutical assistance program. Many states have a program called
the State Pharmaceutical Assistance Program (SPAP) that helps people pay for prescription drugs
based on their financial need, age, or medical condition. To learn more about the program, check
with your State Health Insurance Assistance Program (the name and phone numbers for this
organization are in Addendum A at the back of the Evidence of Coverage).
•
What if you have coverage from an AIDS Drug Assistance Program (ADAP)? The AIDS Drug
Assistance Program (ADAP) helps ADAP‑eligible individuals living with HIV/AIDS have access to
life‑saving HIV medications. Medicare Part D prescription drugs that are also covered by ADAP
qualify for prescription cost‑sharing assistance through the AIDS Drug Assistance Program (ADAP)
for your state. Note: To be eligible for the ADAP operating in your State, individuals must meet
•
OMB Approval 0938-1051 (Expires: February 29, 2024)
12 Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024
certain criteria, including proof of State residence and HIV status, low income as defined by the
State, and uninsured/under‑insured status.
If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D
prescription cost‑sharing assistance for drugs on the ADAP formulary. In order to be sure you
continue receiving this assistance, please notify your local ADAP enrollment worker of any changes
in your Medicare Part D plan name or policy number.
For information on eligibility criteria, covered drugs, or how to enroll in the program, please call the
ADAP for your state (the name and phone number for this organization is in Addendum A at the
back of the Evidence of Coverage.
•
SECTION 7 Questions?
Section 7.1 Getting Help from Aetna Medicare Plan (PPO)
Questions? We’re here to help. Please call Member Services at the telephone number on your member ID
card or call our general Member Services at 1‑833‑383‑4612. (TTY only, call 711.) We are available for
phone calls 8 AM to 9 PM ET, Monday through Friday. Calls to these numbers are free.
Read your 2024 Evidence of Coverage (it has details about next year's benefits and costs)
ThisAnnual Notice of Changes gives you a summary of changes in your benefits and costs for 2024. For
details, look in the 2024 Evidence of Coverage and the Schedule of Cost Sharing for Aetna Medicare Plan
(PPO). The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your
rights and the rules you need to follow to get covered services. A copy of the Evidence of Coverage is
located on our website at STRS.AetnaMedicare.com. The Schedule of Cost Sharing lists the out‑of‑pocket
cost share for your plan; a copy is also located on the STRS.AetnaMedicare.com website. You can request
a mailed copy of either of these materials directly from the website or by calling Member Services.
Visit our Website
You can also visit our website at STRS.AetnaMedicare.com. As a reminder, our website has the most
up‑to‑date information about our provider network (Provider Directory).
Section 7.2 Getting Help from Medicare
To get information directly from Medicare:
Call 1‑800‑MEDICARE (1‑800‑633‑4227)
You can call 1‑800‑MEDICARE (1‑800‑633‑4227), 24 hours a day, 7 days a week. TTY users should call
1‑877‑486‑2048.
Visit the Medicare Website
You canvisit the Medicare website (www.medicare.gov). It has information about cost, coverage, and
quality ratings to help you compare Medicare health plans in your area. To view the information about
plans, go towww.medicare.gov/plan-compare.
Read Medicare & You 2024
Read the Medicare & You 2024 handbook. Every fall, this document is mailed to people with Medicare. It
has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked
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Aetna Medicare Plan (PPO)Annual Notice of Changes for 2024 13
questions about Medicare. If you don’t have a copy of this document, you can get it at the Medicare
website (https://www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf) or by calling
1‑800‑MEDICARE (1‑800‑633‑4227), 24 hours a day, 7 days a week. TTY users should call
1‑877‑486‑2048.
OMB Approval 0938-1051 (Expires: February 29, 2024)
See the Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by service area.
Out‑of‑network/non‑contracted providers are under no obligation to treat Aetna members, except in
emergency situations. Please call our Member Services number or see your Evidence of Coverage for
more information, including the cost‑sharing that applies to out‑of‑network services.
To send a complaint to Aetna, call the Plan or the number on your member ID card. To send a complaint to
Medicare, call 1‑800‑MEDICARE (TTY users should call 1‑ 877‑486‑2048), 24 hours a day/7 days a week).
If your complaint involves a broker or agent, be sure to include the name of the person when filing your
grievance.
OMB Approval 0938-1051 (Expires: February 29, 2024)
We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color,
national origin, age, disability, or sex and does not exclude people or treat them differently because of
race, color, national origin, age, disability, or sex. If you speak a language other than English, free language
assistance services are available. Visit our website, call the phone number listed in this material or the
phone number on your benefit ID card.
In addition, your health plan provides auxiliary aids and services, free of charge, when necessary to ensure
that people with disabilities have an equal opportunity to communicate effectively with us. Your health
plan also provides language assistance services, free of charge, for people with limited English
proficiency. If you need these services, call Customer Service at the phone number on your benefit ID
card.
If you believe that we have failed to provide these services or discriminated in another way on the basis of
race, color, national origin, age, disability, or sex, you can file a grievance with our Grievance Department
(write to the address listed in your Evidence of Coverage). You can also file a grievance by phone by
calling the Customer Service phone number listed on your benefit ID card (TTY: 711). If you need help filing
a grievance, call Customer Service Department at the phone number on your benefit ID card.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights at https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf.
ESPAÑOL (SPANISH): Si habla un idioma que no sea inglés, se encuentran disponibles servicios gratuitos
de asistencia de idiomas. Visite nuestro sitio web o llame al número de teléfono que figura en este
documento.
繁體中文 (CHINESE): 如果您使用英文以外的語言，我們將提供免費的語言協助服務。請瀏覽我們的網站或撥
打本文件中所列的電話號碼。
How we guard your privacy
What personal information is — and what it isn’t
By “personal information,” we mean information that can be used to identify you. It can include financial
and health information. It doesn’t include what the public can easily see. For example, anyone can look at
what your plan covers.
How we get information about you
We get information about you from many sources, including you. We also get information from your
employer, other insurers, or health care providers like doctors.
When information is wrong
Do you think there’s something wrong or missing in your personal information? You can ask us to change
it. The law says we must do this in a timely way. If we disagree with your change, you can file an appeal.
Information on how to file an appeal is on our member website. Or you can call the toll‑free number on
your ID card.
How we use this information
When the law allows us, we use your personal information both inside and outside our company. The law
says we don’t need to get your OK when we do. We may use it for your health care or use it to run our
plans. We also may use your information when we pay claims or work with other insurers to pay claims.
We may use it to make plan decisions, to do audits, or to study the quality of our work. This means we may
share your information with doctors, dentists, pharmacies, hospitals or other caregivers. We also may
share it with other insurers, vendors, government offices, or third‑party administrators. But by law, all
these parties must keep your information private.
When we need your permission
There are times when we do need your permission to disclose personal information. This is explained in
our Notice of Privacy Practices, which took effect October 10, 2020. This notice clarifies how we use or
disclose your Protected Health Information (PHI):
For workers’ compensation purposes•
As required by law•
About people who have died•
For organ donation•
To fulfill our obligations for individual access and HIPAA compliance and enforcement•
To get a copy of this notice, just visit our member website or call the toll‑free number on your ID card.
Form Approved
OMB#0938‑1421
Multi‑Language Insert
Multi‑language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our health or
drug plan. To get an interpreter, just call us at 1‑833‑383‑4612. Someone who speaks English/Language
can help you. This is a free service.
Spanish:Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que
pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame
al 1‑833‑383‑4612. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin:我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。如果您需要此
翻译服务，请致电 1‑833‑383‑4612。我们的中文工作人员很乐意帮助您。 这是一项免费服务。
Chinese Cantonese:您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯 服務。如需翻譯
服務，請致電 1‑833‑383‑4612。我們講中文的人員將樂意為您提供幫助。這 是一項免費服務。
Tagalog:Mayroon kaming libreng serbisyo sa pagsasaling‑wika upang masagot ang anumang mga
katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng
tagasaling‑wika, tawagan lamang kami sa 1‑833‑383‑4612. Maaari kayong tulungan ng isang
nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French:Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions
relatives à notre régime de santé ou d'assurance‑médicaments. Pour accéder au service
d'interprétation, il vous suffit de nous appeler au 1‑833‑383‑4612. Un interlocuteur parlant Français
pourra vous aider. Ce service est gratuit.
Vietnamese:Chúng tôi có d
‑833‑383‑4612. s
German:Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits‑
und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1‑833‑383‑4612. Man wird Ihnen dort auf
Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean:당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습
니다. 통역 서비스를 이용하려면 전화 1‑833‑383‑4612. 번으로 문의해 주십시오. 한국어를 하는 담당자가 도
와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian:
‑833‑383‑4612.
‑p
:Arabic
. ‑‑‑
Hindi:
‑833‑383‑4612.
Italian:È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro
piano sanitario e farmaceutico. Per un interprete, contattare il numero 1‑833‑383‑4612. Un nostro
incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
Portuguese:Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que
tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte‑nos através
do número 1‑833‑383‑4612. Irá encontrar alguém que fale o idioma Português para o ajudar. Este
serviço é gratuito.
French Creole:Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan
medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1‑833‑383‑4612. Yon moun ki pale
Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish:Umo
‑833‑383‑4612. Ta us
Japanese:当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無料の通訳サ
ービスがありますございます。通訳をご用命になるには、1‑833‑383‑4612. にお電話ください。日本語を話
す人 者 が支援いたします。これは無料のサー ビスです。
Hawaiian:He k
‑833‑383‑4612. E hiki ana i kekahi mea
Y0001_NR_30475b_2023_C
Form CMS‑10802
(Expires 12/31/25)
Aetna Medicare Plan (PPO)Member Services
Method Member Services – Contact Information
CALL
The number on your member ID card or 1‑833‑383‑4612.
Calls to this number are free.
Hours of operation are 8 AM to 9 PM ET, Monday through
Friday.
Member Services also has free language interpreter services
available for non‑English speakers.
TTY
711
Calls to this number are free.
Hours of operation are 8 AM to 9 PM ET, Monday through Friday.
WRITE
Aetna Medicare
PO Box 7082
London, KY 40742
WEBSITE
STRS.AetnaMedicare.com
