$250 per member. All covered expenses accumulate separately toward the Network and Out-of-network Coinsurance Maximum.

Transcription

1 PLAN FEATURES Network Managed Choice POS (Open Access) OUT-OF- Not Applicable Primary Care Physician Selection Deductible (per calendar year) Not Applicable $250 per member Not Applicable $250 per member (2-member maximum) (2-member maximum) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate separately toward the Network and Out-of-Network Deductible. Member cost sharing for certain services including member cost sharing for prescription drugs, as indicated in the plan, are excluded from charges to meet the Deductible. Once 2 individual members of a family each satisfy their Deductible amount separately, all family members will be considered as having met their Deductible for the remainder of the calendar year. Member Coinsurance (applies to all expenses unless otherwise stated) 20% 40% Coinsurance Maximum (per calendar year, excludes deductible) $3,500 Individual $7,000 Individual (2-member maximum) (2-member maximum) All covered expenses accumulate separately toward the Network and Out-of-network Coinsurance Maximum. Certain member cost sharing elements may not apply toward the Coinsurance Maximum. Amounts over allowable, copays, DME, failure to pre-certify penalty, infertility, non-smi-sed mental disorders, Rx (including self-injectables) and substance abuse do not apply toward the Coinsurance Maximum and continue to be payable after the maximum is reached. Once 2 individual members of a family each satisfy their Coinsurance Maximum separately, all family members will be considered as having met their Coinsurance Maximum for the remainder of the calendar year. Health Incentive Credit Program/Simple Steps Health Assessment and one Online Wellness Program Reward of $50.00 per employee and/or spouse with a family limit of $ per year for completion of the Health Assessment and one Online Wellness Program. Incentive Rewards will be credited towards the deductible and Payment Limit. Lifetime Maximum Payment for Out-of-Network Care* Not Applicable Unlimited Professional: 180% of Medicare Facility: 100% of Medicare Certification Requirements Certification for certain types of Out-of-Network care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, and Hospice Care is required. Benefits will be reduced by $400 per occurrence if Certification is not obtained. Referral Requirement PHYSICIAN SERVICES Office Visits to Non-Specialist None None OUT-OF- Includes services of an internist, general physician, family practitioner or pediatrician for routine care as well as diagnosis and treatment of an illness or injury and in-office surgery. Specialist Office Visits Page 1

2 E-Visits - Primary Care & Specialist $10 copay; deductible waived Physicians An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through an Aetna authorized internet E-visit service vendor. Register at Walk-in Clinics Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor an outpatient department of a hospital, shall be considered a Walk-in Clinic. Pre-Natal Maternity Maternity - Delivery Post-Partum Care Surgery (in office) and Allergy Testing (given by a physician) Allergy Injections (not given by a physician) PREVENTIVE CARE Routine Adult Physical Exams and Immunizations Limited to 1 exam every 12 months for members age 18 and older. Well Child Exams and Immunizations Provides coverage for 9 exams from birth up to age 3; 1 exam per 12 months from age 3 through age 17. Routine Gynecological Exams Includes Pap smear, HPV screening and related lab fees. Frequency schedule applies. Routine Mammograms For covered females age 40 and over. Frequency schedule applies. Women's Health Includes: Screening for gestational diabetes; HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections; counseling and screening for human immunodeficiency virus; screening and counseling for interpersonal and domestic violence; breastfeeding support, supplies and counseling; and contraceptive methods and counseling. Limitations may apply. (copay waived when office visit charge is not made.) OUT-OF- place of service where it is rendered Page 2

3 Routine Digital Rectal Exam / Prostate-Specific Antigen Test For covered males age 40 and over. Frequency schedule applies. Colorectal Cancer Screening Sigmoidoscopy and Double Contrast Barium Enema - 1 every 5 years for all members age 50 and over. Preventive Colonoscopy - 1 every 10 years for all members age 50 and over. Fecal Occult Blood Testing - 1 every year for all members age 50 and over. Colonoscopy (non-preventive) Routine Eye and Hearing Screenings See Outpatient Surgery Benefit Paid as part of routine physical exam. See Outpatient Surgery Benefit Paid as part of routine physical exam. Routine Eye Exams (Refraction) Limited to 1 exam every 24 months. DIAGNOSTIC PROCEDURES Outpatient Diagnostic Laboratory and X-ray (except for Complex Imaging Services) Outpatient Complex Imaging Services Including, but not limited to, MRI, MRA, PET and CT Scans. Precertification required. No charge for the first $300 per member, thereafter covered at 20% after deductible OUT-OF- 50% after deductible. Maximum payment of $800 per service. EMERGENCY MEDICAL CARE Urgent Care Provider (Benefit Availability may vary by location.) Non-Urgent Use of Urgent Care Provider Emergency Room Copay waived if admitted. Copay applies to facility charges only. Non-Emergency care in an Emergency Room Ambulance HOSPITAL CARE Inpatient Coverage Including maternity (prenatal, delivery and postpartum) & transplants Outpatient Surgery Provided in an outpatient hospital department OUT-OF- $50 copay; deductible waived $50 copay; deductible waived $150 copay plus Paid as Network Care Paid as Network Care OUT-OF- $250 copay plus 30% after deductible 50% after deductible. Maximum payment of $400 per surgery. Page 3

4 Outpatient Surgery 20%; deductible waived. Maximum Provided in a freestanding surgical facility payment of $400 per surgery. Outpatient Hospital Services other than Surgery Including, but not limited to, physical therapy, speech therapy, occupational therapy, spinal manipulation, dialysis, radiation therapy. Outpatient Other than Serious Mental Illness or Serious Emotional Disturbances of a Child Limited to 20 visits per member per calendar year. Network and Out-of-Network combined. ALCOHOL / DRUG ABUSE SERVICES Inpatient Detoxification Limited to 3 days per admission, 2 admissions per calendar year. Network and Out-of- Network combined. Outpatient Detoxification Inpatient and Outpatient Rehabilitation OTHER SERVICES AND PLAN DETAILS Autism Treatment Skilled Nursing Facility Limited to 60 days per member per calendar year. Network and Out-of-Network combined. Home Health Care Limited to 90 visits per member per calendar year. Network and Out-of-Network combined; 1 visit equals a period of 4 hours or less. Infusion Therapy Provided in the home or physician's office Infusion Therapy Provided in an outpatient hospital department or freestanding facility Inpatient Hospice Care. Maximum benefit of $300 per visit. MENTAL HEALTH SERVICES Inpatient Serious Mental Illness or Serious Emotional Disturbances of a Child OUT-OF- $250 copay plus Outpatient Serious Mental Illness or Serious Emotional Disturbances of a Child Inpatient Other than Serious Mental Illness or Serious Emotional Disturbances of a Child. Maximum benefit of $100 per visit. OUT-OF- $250 copay plus. Maximum benefit of $175 per day. place rendered OUT-OF- place rendered $250 copay plus. Maximum benefit of $200 per day.. Maximum benefit of $100 per visit.. 30% after deductible. $250 copay plus. Maximum benefit of $300 per day. Page 4

5 Outpatient Hospice Care Private Duty Nursing - Outpatient Outpatient Short-Term Rehabilitation. Maximum Includes physical, occupational and chiropractic benefit of $50 per visit. therapy (if provided in the outpatient hospital department, paid under outpatient hospital benefit). Limited to 24 visits per member per calendar year. Network and Out-of-Network combined. Limits do not apply to autism. Outpatient Speech Therapy (if provided in the outpatient hospital department, paid under outpatient hospital benefit) Limited to 20 visits per member per calendar year. Network and Out-of-Network combined. Limits do not apply to autism. Acupuncture Limited to 12 visits per member per calendar year. Durable Medical Equipment Maximum benefit of $2,000 per member per calendar year. Limit does not apply to prosthetics or orthotics. Network and Out-of- Network combined.. 50% after deductible 50% after deductible. Diabetic Supplies not obtainable at a pharmacy Covered same as any other medical expense Covered same as any other medical expense Contraceptive drugs and devices not FAMILY PLANNING OUT-OF- Infertility Treatment Covered only for the diagnosis and treatment of the underlying medical condition Voluntary Sterilization - Vasectomy Voluntary Sterilization - Tubal Ligation place rendered No charge place rendered 40%; deductible waived PHARMACY - PRESCRIPTION DRUG BENEFITS PARTICIPATING PHARMACIES NON-PARTICIPATING PHARMACIES Page 5

6 Retail Up to a 30-day supply Mail Order Delivery Up to a 90-day supply $15 copay for generic drugs, $40 copay for brand name formulary drugs, and $50 copay for brand name nonformulary drugs $30 copay for generic drugs, $80 copay for brand name formulary drugs, and $100 copay for brand name nonformulary drugs Specialty Care Rx SM Includes self-injectable, infused and oral 30% up to $250 per prescription for formulary and non-formulary drugs Specialty CareRx SM - First Prescription for a self-injectable drug must be filled at a participating retail pharmacy or Aetna Specialty Pharmacy. Subsequent fills must be through Aetna Specialty Pharmacy. Mandatory Generic with DAW override (MG w/daw Override) - The member pays the applicable copay only, if the physician requires brand. If the member requests brand when a generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Plan includes: Contraceptive drugs and devices obtainable from a pharmacy and diabetic supplies obtainable from a pharmacy Formulary generic Lifestyle/performance FDA-approved drugs Women s limited Contraceptives to 4 pills per month covered Precerticifation 100% in network. included and 90 day Transition of Care *We cover the cost of services based on whether doctors are "in-network" or "out-of-network". We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this "out-of-network" care. You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out-of-network, your Aetna health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the "recognized" or "allowed" amount. When you choose out-of-network care, Aetna "recognizes" an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher - sometimes much higher - than what your Aetna plan "recognizes" Your doctor may bill you for the dollar amount that Aetna doesn't "recognize" You must also pay any To learn more about how we pay out-of-network benefits visit Aetna.com. Type "how Aetna pays" in the search box. You can avoid these extra costs by getting your care from Aetna's broad network of health care providers. Go to and click on "Find a Doctor" on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. Page 6

7 This applies when you choose to get care out-of-network. When you have no choice (for example: emergency room visit after What's This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan Ÿ All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Ÿ Charges related to any eye surgery mainly to correct refractive errors; Ÿ Cosmetic surgery, including breast reduction; Ÿ Custodial care; Ÿ Dental care and x-rays; Ÿ Donor egg retrieval; Ÿ Experimental and investigational procedures; Ÿ Hearing aids; Ÿ Immunizations for travel or work; Ÿ Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, Ÿ Non-medically necessary services or supplies; Ÿ Orthotics except as specified in the plan; Ÿ Over-the-counter medications and supplies; Ÿ Reversal of sterilization; Ÿ Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, counseling and prescription Ÿ Special duty nursing; and Ÿ Treatment of those services for or related to treatment of obesity or for diet or weight control. Pre-existing Conditions Exclusion Provision This plan imposes a pre-existing conditions exclusion, which may be waived in some circumstances (that is, creditable Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for Page 7

8 If you had less than 6 months of group or three months of individual (including Medicare, Medicaid and Medi-Cal) of creditable If you had no prior creditable coverage within the 6 months for group or 3 months for individual prior to your enrollment date In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy The pre-existing condition exclusion does not apply to pregnancy or to a child under the age of 19. Note: For late enrollees, This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to If your plan covers outpatient prescription drugs, your plan may include a drug formulary (preferred drug list). A formulary is a list of prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicable limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. The medications listed on the formulary are subject to change in accordance with applicable state law. For information regarding how medications are reviewed and selected for the formulary, formulary information, and information about other pharmacy Page 8

9 determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna, Inc., that is a licensed pharmacy While this information is believed to be accurate as of the print date, it is subject to change. In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. Plans are provided by. For more information about Aetna plans, refer to a Page 9