2024 Plan Coverage Documents
Review these plan documents for a detailed explanation of coverage. Contact the plan administrator with coverage questions.
The following documents are for the current plan year. For next plan year’s documents, check out our 2025 Plan Coverage Documents page.
Health care program
Medical
All enrollees
Aetna Medicare Plan
All enrollees
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
SilverScript (Medicare enrollees)
CVS Caremark (non-Medicare enrollees)
Dental and vision
Delta Dental
Vision Service Plan (VSP)
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