HMO 23.6 (08/12) PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)

Transcription

1 PLAN FEATURES Deductible (per clendr yer) None Individul None Fmily Out-of-Pocket Mximum $3,500 Individul (per clendr yer) $7,000 Fmily Member cost shring for certin services my not pply towrd the Out-of-Pocket Mximum. Only those prticipting providers/referred out of pocket expenses resulting from the ppliction of coinsurnce percentge nd copys (except ny penlty mounts nd phrmcy cost shring) my be used to stisfy the Out-of Pocket Mximum. Once Fmily Out-of-Pocket Mximum is met, ll fmily members will be considered s hving met their Out-of-Pocket Mximum for the reminder of the clendr yer. Lifetime Mximum Unlimited Primry Cre Physicin Selection Referrl Requirements Required Required for ll non-emergency, non-urgent nd non- Primry Cre Physicin services, except direct ccess services PREVENTIVE CARE Routine Adult Physicl Exms / Immuniztions One exm every 12 months ge 18 nd over. Well Child Exms / Immuniztions 7 exms in the first 12 months of life, 3 exms in the second 12 months of life, 3 exms in the third 12 months of life, 1 exm every 12 months therefter. Includes immuniztions. Routine Gynecologicl Cre Exms Includes Pp smer, HPV screening, nd relted lb fees. One routine exm every 12 months. Direct ccess to prticipting providers in the sme medicl group s PCP without referrl. Routine Mmmogrms One bseline mmmogrm for femles ge 35-39; nd one nnul mmmogrm for femles ge 40 nd over Women's Helth Includes: Screening for gesttionl dibetes; HPV (Humn Ppillomvirus) DNA testing, counseling for sexully trnsmitted infections; counseling nd screening for humn immunodeficiency virus; screening nd counseling for interpersonl nd domestic violence; brestfeeding support, supplies nd counseling; nd contrceptive methods nd counseling. Limittions my pply. Routine Digitl Rectl Exms / Prostte Specific Antigen Test For mles ge 40 nd over Colorectl Cncer Screening For ll members 50 nd over. Frequency schedule pplies Routine Eye Exm One exm every 24 months. Direct ccess to prticipting providers without referrl. Routine Hering Screening Covered s prt of Routine Adult/Well Child Exm AETNA LIFE INSURANCE COMPANY Pge 1 (v )

2 PHYSICIAN SERVICES Primry Cre Physicin Visits Office Hours: $40 copy After Office Hours/Home: $45 copy Specilist Office Visits $50 copy Pre-Ntl Mternity Mternity - Delivery nd Post-Prtum Cre $40 copy Allergy Tretment Sme s pplicble prticipting provider office visit member cost shring Allergy Testing Sme s pplicble prticipting provider office visit member cost shring DIAGNOSTIC PROCEDURES Dignostic Lbortory If performed s prt of physicin's office visit nd billed by the physicin, expenses re covered subject to the pplicble physicin's office visit cost shring. Dignostic X-ry $50 copy Outptient hospitl or other Outptient fcility (except for Complex Imging Services) Dignostic X-ry for Complex Imging Services $100 copy EMERGENCY MEDICAL CARE Urgent Cre $35 copy Non-Urgent use of Urgent Cre Provider Emergency Room $100 copy Non-Emergency Cre in n Emergency Room Emergency Use of Ambulnce $100 copy Non-Emergency Use of Ambulnce HOSPITAL CARE Inptient Coverge $1,000 per dy for the first 3 dys per dmission, therefter Inptient Mternity Coverge $1,000 per dy for the first 3 dys per dmission, therefter Outptient Surgery in Hospitl $500 per visit Outptient Surgery in Free Stnding Fcility $200 per visit MENTAL HEALTH SERVICES Inptient Serious Mentl Illness nd Serious Emotionl Disturbnces of Child $1,000 per dy for the first 3 dys per dmission, therefter Inptient Non-Serious Mentl Illness $1,000 per dy for the first 3 dys per dmission, therefter Outptient Serious Mentl Illness nd Serious Emotionl $50 copy per visit Disturbnces of Child Outptient Non-Serious Mentl Illness $50 copy per visit ALCOHOL/DRUG ABUSE SERVICES Inptient Detoxifiction $1,000 per dy for the first 3 dys per dmission, therefter Outptient Detoxifiction $50 copy Inptient Rehbilittion $1,000 per dy for the first 3 dys per dmission, therefter Outptient Rehbilittion $50 copy AETNA LIFE INSURANCE COMPANY Pge 2 (v )

3 OTHER SERVICES Autism Tretment Member cost shring is bsed on the type of service performed nd the plce of service where it is Skilled Nursing Fcility $1,000 per dy for the first 3 dys per dmission, Limited to 100 dys per clendr yer therefter Home Helth Cre $40 copy Limited to 100 dys per clendr yer Limited to 3 intermittent visits per dy by prticipting home helth cre gency; 1 visit equls period of 4 hrs or less. Hospice Cre - Inptient $1,000 per dy for the first 3 dys per dmission, therefter Hospice Cre - Outptient Privte Duty Nursing Outptient Rehbilittion Therpy (Includes speech, $50 copy physicl nd occuptionl therpy) Tretment over 60-dy consecutive period per incident of illness or injury beginning with the first dy of tretment for combined therpies. Limits do not pply to utism. Chiroprctic/Subluxtion $15 copy Limited to 20 visits per clendr yer Durble Medicl Equipment 50% Limited to $2,000 per clendr yer Dibetic Supplies Phrmcy cost shring pplies Dentl Vision Eyewer Trnsplnts $1,000 per dy for the first 3 dys per dmission, Coverge is provided t n IOE contrcted fcility only therefter Britric Surgery $1,000 per dy for the first 3 dys per dmission, therefter FAMILY PLANNING Infertility Tretment Member cost shring is bsed on the type of service Dignosis nd tretment of the underlying medicl condition. performed nd the plce of service where it is Voluntry Steriliztion - Vsectomy Member cost shring is bsed on the type of service performed nd the plce of service where it is Voluntry Steriliztion Tubl Ligtion PHARMACY - PRESCRIPTION DRUG BENEFITS Retil $15 copy for formulry generic drugs, $35 copy for formulry brnd-nme drugs, nd $50 copy for nonformulry brnd-nme nd generic drugs up to 30 dy supply t prticipting phrmcies. Mil Order $30 copy for formulry generic drugs, $70 copy for formulry brnd-nme drugs, nd $100 copy for nonformulry brnd-nme nd generic drugs up to dy supply from Aetn Rx Home Delivery No Mndtory Generic (NO MG) - Member is responsible to py the pplicble copy only. Pln Includes: Contrceptive drugs nd devices obtinble from phrmcy nd Performnce Enhncing Mediction. Precert included with 90 dy Trnsition of Cre for New Business Formulry generic FDA-pproved Women s Contrceptives covered 100% in network.. EXCLUSIONS AND LIMITATIONS **For this pln, "prticipting providers" refers to the Aetn HMO prticipting providers. For ny questions or concerns bout ccessing nd obtining services from Aetn HMO specilty physicins, plese cll Member Services t AETNA ( ) or go to AETNA LIFE INSURANCE COMPANY Pge 3 (v )

4 Plns re provided by: Aetn Helth of Cliforni Inc. While this mteril is believed to be ccurte s of the production dte, it is subject to chnge. See pln documents for complete description of benefits, exclusions, limittions nd conditions of coverge. Pln fetures nd vilbility my vry by loction nd re subject to chnge. You my be responsible for the helth cre provider's full chrges for ny non-covered services, including circumstnces where you hve exceeded benefit limit contined in the pln. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. If you re in pln tht requires the selection of primry cre physicin nd your primry cre physicin is prt of n integrted delivery system or physicin group, your primry cre physicin will generlly refer you to specilists nd hospitls tht re ffilited with the delivery system or physicin group. The following is list of services nd supplies tht re generlly not covered. However, your pln documents my contin exceptions to this list bsed on stte mndtes or the pln design or rider(s) purchsed by your employer. All medicl nd hospitl services not specificlly covered in, or which re limited or excluded by your pln documents Cosmetic surgery, including brest reduction Custodil cre Dentl cre nd dentl x-rys Donor egg retrievl Durble medicl equipment Experimentl nd investigtionl procedures, except for coverge for mediclly necessry routine ptient cre costs for members prticipting in cncer clinicl tril) Hering ids Home births Immuniztions for trvel or work except where mediclly necessry or indicted Implntble drugs nd certin injectble drugs including injectble infertility drugs Infertility services, including rtificil insemintion nd dvnced reproductive technologies such s IVF, ZIFT, GIFT, ICSI nd other relted services, unless specificlly listed s covered in your pln documents Long-term rehbilittion therpy Non-mediclly necessry services or supplies Orthotics except dibetic orthotics Outptient prescription drugs (except for tretment of dibetes), unless covered by prescription pln rider nd overthe-counter medictions (except s provided in hospitl) nd supplies Rdil kertotomy or relted procedures Reversl of steriliztion Services for the tretment of sexul dysfunction or indequcies including therpy, supplies or counseling or prescription drugs Specil duty nursing Therpy or rehbilittion other thn those listed s covered Tretment of behviorl disorders Weight control services including medicl tretments, weight control/loss progrms, dietry regimens nd supplements, ppetite suppressnts nd other medictions; food or food supplements, exercise progrms, exercise or other equipment; nd other services nd supplies tht re primrily intended to control weight or tret obesity, including Morbid Obesity, or for the purpose of weight reduction, regrdless of the existence of comorbid conditions Aetn receives rebtes from drug mnufcturers tht my be tken into ccount in determining Aetn's Preferred Drug List. Rebtes do not reduce the mount member pys the phrmcy for covered prescriptions. Aetn Rx Home Delivery refers to Aetn Rx Home Delivery, LLC, licensed phrmcy subsidiry of Aetn Inc., tht opertes through mil order. The chrges tht Aetn negotites with Aetn Rx Home Delivery my be higher thn the cost they py for the drugs nd the cost of the mil order phrmcy services they provide. For these purposes, the phrmcy's cost of purchsing drugs tkes into ccount discounts, credits nd other mounts tht they my receive from wholeslers, mnufcturers, suppliers nd distributors. AETNA LIFE INSURANCE COMPANY Pge 4 (v )

5 In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Trnsltion of the mteril into nother lnguge my be vilble. Plese cll Member Services t AETNA ( ). Puede estr disponible l trduccion de este mteril en otro idiom. Por fvor llme Servicios l Miembro l AETNA ( ). Pln fetures nd vilbility my vry by loction nd group size. For more informtion bout Aetn plns, refer to AETNA LIFE INSURANCE COMPANY Pge 5 (v )