MEMBER COST SHARE. 20% after deductible

Transcription

1 PLAN FEATURES Network Primry Cre Physicin Selection Deductible (per clendr yer) Unless otherwise indicted, the Deductible must be met prior to benefits being pyble. Not Applicble Not Applicble $500 Individul (2-member mximum) Member cost shring for certin services including member cost shring for prescription drugs, s indicted in the pln, re excluded from chrges to meet the Deductible. Once 2 individul members of fmily ech stisfy their Deductible mount seprtely, ll fmily members will be considered s hving met their Deductible for the reminder of the clendr yer. Member Coinsurnce (pplies to ll expenses unless otherwise stted) Coinsurnce mximum (per clendr yer, excludes deductible) 20% $3,500 Individul (2-member mximum) Certin member cost shring elements my not pply towrd the Coinsurnce Mximum. Amounts over llowble, copys, DME, filure to pre-certify penlty, infertility, non-smi-sed mentl disorders, Rx (including self-injectbles) nd substnce buse do not pply towrd the Coinsurnce Mximum nd continue to be pyble fter the mximum is reched. Once 2 individul members of fmily ech stisfy their Coinsurnce mximum seprtely, ll fmily members will be considered s hving met their Coinsurnce Mximum for the reminder of the clendr yer. Lifetime Mximum Unlimited Certifiction Requirements Certifiction for certin types of Non-Preferred cre must be obtined to void reduction in benefits pid for tht cre. Certifiction for Hospitl Admissions, Tretment Fcility Admissions, Convlescent Fcility Admissions, Home Helth Cre, nd Hospice Cre is required. Benefits will be reduced by $400 per occurrence if Certifiction is not obtined. Referrl Requirement PHYSICIAN SERVICES Office Visits to Non-Specilist Not Applicble Includes services of n internist, generl physicin, fmily prctitioner or peditricin for routine cre s well s dignosis nd tretment of n illness or injury nd in-office surgery. Specilist Office Visits E-Visits - Primry Cre & Specilist Physicins Wlk-in Clinics Mternity OB Visits Surgery (in office) CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 1

2 Pre-Ntl Mternity No chrge Mternity - Delivery nd Post-Prtum Cre Allergy Testing (given by physicin) Allergy Injections (not given by physicin) PREVENTIVE CARE Routine Adult Physicl Exms nd No chrge Immuniztions Limited to 1 exm every 12 months for members ge 18 nd older. Well Child Exms nd Immuniztions No Chrge Provides coverge for 9 exms from birth up to ge 3; 1 exm per 12 months from ge 3 through ge 17. Routine Gynecologicl Exms No Chrge Includes Pp smer, HPV screening nd relted lb fees. Frequency schedule pplies. Routine Mmmogrms For covered femles ge 40 nd over. Frequency schedule pplies. No Chrge Women's Helth No Chrge 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 Exm / No Chrge Prostte-Specific Antigen Test For covered mles ge 40 nd over. Frequency schedule pplies. Colorectl Cncer Screening No Chrge Sigmoidoscopy nd Double Contrst Brium Enem - 1 every 5 yers for ll members ge 50 nd over. Preventive Colonoscopy - 1 every 10 yers for ll members ge 50 nd over. Fecl Occult Blood Testing - 1 every yer for ll members ge 50 nd over. CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 2

3 Colonoscopy (non-preventive) Routine Eye nd Hering Exms Covered only s prt of routine physicl exm. See Outptient Surgery Benefit Pid s prt of routine physicl exm. DIAGNOSTIC PROCEDURES Outptient Dignostic Lbortory nd X-ry (except for Complex Imging Services) Outptient Complex Imging Services Including, but not limited to, MRI, MRA, PET nd CT Scns. Precertifiction required. EMERGENCY MEDICAL CARE Urgent Cre Provider (Benefit Avilbility my vry by loction.) Non-Urgent Use of Urgent Cre Provider Emergency Room Copy wived if dmitted. Copy pplies to fcility chrges only. Non-Emergency cre in n Emergency Room Ambulnce HOSPITAL CARE Inptient Coverge Including mternity (prentl, delivery nd postprtum) & trnsplnts Outptient Surgery Provided in n outptient hospitl deprtment Outptient Surgery Provided in freestnding surgicl fcility Outptient Hospitl Services other thn Surgery Including, but not limited to, physicl therpy, speech therpy, occuptionl therpy, spinl mnipultion, dilysis, rdition therpy. MENTAL HEALTH SERVICES Inptient Serious Mentl Illness or Serious Emotionl Disturbnces of Child Outptient Serious Mentl Illness or Serious Emotionl Disturbnces of Child $250 copy plus $250 copy plus 30% fter deductible $250 copy plus CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 3

4 Inptient Other thn Serious Mentl Illness or Serious Emotionl Disturbnces of Child Outptient Other thn Serious Mentl Illness or Serious Emotionl Disturbnces of Child ALCOHOL / DRUG ABUSE SERVICES Inptient Detoxifiction $250 copy plus Limited to 3 dys per dmission, 2 dmissions per clendr yer. Outptient Detoxifiction Inptient nd Outptient Rehbilittion OTHER SERVICES AND PLAN DETAILS Autism Tretment Member cost shring is bsed on the type of service performed nd the plce rendered Skilled Nursing Fcility Limited to 60 dys per member per clendr yer. Home Helth Cre Limited to 90 visits per member per clendr yer. 1 visit equls period of 4 hours or less. Infusion Therpy Provided in the home or physicin's office Infusion Therpy Provided in n outptient hospitl deprtment or freestnding fcility Inptient Hospice Cre Outptient Hospice Cre Privte Duty Nursing - Outptient Outptient Short-Term Rehbilittion Includes physicl, occuptionl nd chiroprctic therpy (if provided in the outptient hospitl deprtment, pid under outptient hospitl benefit). Limited to 24 visits per member per clendr yer. Network nd Out-of-Network combined. PT/OT limits do not pply to utism. 30% fter deductible Outptient Speech Therpy (if provided in the outptient hospitl deprtment, pid under outptient hospitl benefit) Limited to 20 visits per member per clendr yer. Network nd Out-of-Network combined. Limits do not pply to utism. CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 4

5 Acupuncture Limited to 12 visits per member per clendr yer. Durble Medicl Equipment 50% fter deductible Mximum benefit of $2,000 per member per clendr yer. Limit does not pply to prosthetics or orthotics. Dibetic Supplies not obtinble t phrmcy FAMILY PLANNING Infertility Tretment Covered only for the dignosis nd tretment of the underlying medicl condition Voluntry Steriliztion - Vsectomy Voluntry Steriliztion - Tubl Ligtion Member cost shring is bsed on the type of service performed nd the plce rendered Member cost shring is bsed on the type of service performed nd the plce rendered No chrge PHARMACY - PRESCRIPTION DRUG BENEFITS Prescription Drug Clendr Yer Deductible (must be stisfied before ny prescription drug benefits re pid) Applies to brnd formulry nd brnd non-formulry drugs only. Retil Up to 30-dy supply Mil Order Delivery dy supply Self-Administered Injectbles/Specilty CreRx (Excluding insulin) Does not ccumulte towrd Coinsurnce mximum. PARTICIPATING PHARMACIES $150 per member $10 copy for generic drugs, $25 copy for brnd nme formulry drugs, nd $50 copy for brnd nme non-formulry drugs $20 copy for generic drugs, $50 copy for brnd nme formulry drugs, nd $100 copy for brnd nme non-formulry drugs 30% up to $250 per prescription for formulry nd non-formulry drugs Specilty CreRx - First Prescription for self-injectble drug must be filled t prticipting retil phrmcy or Aetn Specilty Phrmcy. Subsequent fills must be through Aetn Specilty Phrmcy. Mndtory Generic with DAW override (MG w/daw Override) - The member pys the pplicble copy only, if the physicin requires brnd. If the member requests brnd when generic is vilble, the member pys the pplicble copy plus the difference between the generic price nd the brnd price. Pln includes: Contrceptive drugs nd devices obtinble from phrmcy nd dibetic supplies obtinble from phrmcy. Lifestyle/performnce drugs limited to 4 pills per month. Precertifiction included nd 90-dy Trnsition of Cre (TOC) for Precertifiction included. Formulry generic FDA-pproved Women s Contrceptives covered 100% in network. CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 5

6 *Pyment for cre is determined bsed upon the lowest of: the provider's usul chrge for furnishing it; or the chrge Aetn determines to be pproprite, bsed on fctors such s the cost of providing the sme or similr service or supply nd the mnner in which chrges for the service or supply re mde. These chrges re referred to in your pln s "resonble" or "recognized" chrges. Wht's This pln does not cover ll helth cre expenses nd includes exclusions nd limittions. Members should refer to their pln documents to determine which helth cre services re covered nd to wht extent. The following is prtil 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 purchsed. All medicl or hospitl services not specificlly covered in, or which re limited or excluded in the pln documents; Chrges relted to ny eye surgery minly to correct refrctive errors; Cosmetic surgery, including brest reduction; Custodil cre; Dentl cre nd x-rys; Donor egg retrievl; Experimentl nd investigtionl procedures; Hering ids; Immuniztions for trvel or work; Infertility services, including, but not limited to, 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; Non-mediclly necessry services or supplies; Orthotics except s specified in the pln; Over-the-counter medictions nd supplies; Reversl of steriliztion; Services for the tretment of sexul dysfunction or indequcies, including therpy, supplies, counseling nd prescription Specil duty nursing; nd Tretment of those services for or relted to tretment of obesity or for diet or weight control. Pre-existing Conditions Exclusion Provision This pln imposes pre-existing conditions exclusion, which my be wived in some circumstnces (tht is, creditble coverge) nd my not be pplicble to you. A pre-existing conditions exclusion mens tht if you hve medicl condition before coming to our pln, you might hve to wit certin period of time before the pln will provide coverge for tht condition. This exclusion pplies only to conditions for which medicl dvice, dignosis or tretment ws recommended or received or for which the individul took prescribed drugs within 6 months. Generlly, this period ends the dy before your coverge becomes effective. However, if you were in witing period for coverge, the 6 month period ends on the dy before the witing period begins. The exclusion period, if pplicble, my lst up to 6 months from your first dy of coverge, or, if you were in witing period, from the first dy of your witing period. CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 6

7 If you hd less thn 6 months of group or three months of individul (including Medicre, Medicid nd Medi-Cl) of creditble coverge immeditely before the dte you enrolled, your pln's pre-existing conditions exclusion period will be reduced by the mount (tht is, number of dys) of tht prior coverge. If you hd no prior creditble coverge within the 6 months for group or 3 months for individul prior to your enrollment dte (either becuse you hd no prior coverge or becuse there ws more thn 6 months of group or 3 months of individul gp from the dte your prior coverge terminted to your enrollment dte), we will pply your pln's pre-existing conditions exclusion. In order to reduce or possibly eliminte your exclusion period bsed on your creditble coverge, you should provide us copy of ny Certifictes of Creditble Coverge you hve. Plese contct your Aetn Member Services representtive t for MC plns if you need ssistnce in obtining Certificte of Creditble Coverge from your prior crrier or if you hve ny questions on the informtion noted bove. The pre-existing condition exclusion does not pply to pregnncy or to child under the ge of 19. Note: For lte enrollees, coverge will be delyed until the pln's next open enrollment; the pre-existing exclusion will be pplied from the individul's effective dte of coverge. This mteril is for informtionl purposes only nd is neither n offer of coverge nor medicl dvice. It contins only prtil, generl description of pln benefits or progrms nd does not constitute contrct. Aetn does not provide helth cre services nd, therefore, cnnot gurntee results or outcomes. Consult the pln documents (i.e. Group Insurnce Certificte nd/or Group Policy) to determine governing contrctul provisions, including procedures, exclusions nd limittion relting to the pln. With the exception of Aetn Rx Home Delivery, ll preferred providers nd vendors re independent contrctors in privte prctice nd re neither employees nor gents of Aetn or its ffilites. Aetn Rx Home Delivery, LLC, is subsidiry of Aetn Inc. The vilbility of ny prticulr provider cnnot be gurnteed, nd provider network composition is subject to chnge without notice. Certin services require precertifiction, or prior pprovl of coverge. Filure to precertify for these services my led to substntilly reduced benefits or denil of coverge. Some of the benefits requiring precertifiction my include, but re not limited to, inptient hospitl, inptient mentl helth, inptient skilled nursing, outptient surgery, substnce buse (detoxifiction, inptient nd outptient rehbilittion). When the Member s preferred provider is coordinting cre, the preferred provider will obtin the precertifiction. Precertifiction requirements my vry. If your pln covers outptient prescription drugs, your pln my include drug formulry (preferred drug list). A formulry is list of prescription drugs generlly covered under your prescription drug benefits pln on preferred bsis subject to pplicble limittions nd conditions. Your phrmcy benefit is generlly not limited to the drugs listed on the formulry. The medictions listed on the formulry re subject to chnge in ccordnce with pplicble stte lw. For informtion regrding how medictions re reviewed nd selected for the formulry, formulry informtion, nd informtion bout other phrmcy progrms such s precertifiction nd step-therpy, plese refer to Aetn's website t Aetn.com, or the Aetn Mediction Formulry Guide. 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. In ddition, in circumstnces where your prescription pln utilizes copyments or coinsurnce clculted on percentge bsis or deductible, use of formulry drugs my not necessrily result in lower costs for the member. Members should consult with their treting physicins regrding questions bout specific medictions. Refer to your pln documents or contct Member Services for informtion regrding the terms nd limittions of coverge. CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 7

8 Aetn Rx Home Delivery refers to Aetn Rx Home Delivery, LLC, subsidiry of Aetn, Inc., tht is licensed phrmcy providing mil-order phrmcy services. Aetn's negotited chrge with Aetn Rx Home Delivery my be higher thn Aetn Rx Home Delivery's cost of purchsing drugs nd providing mil-order phrmcy services. While this informtion is believed to be ccurte s of the print dte, it is subject to chnge. In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Plns re provided by Aetn Life Insurnce Compny. For more informtion bout Aetn plns, refer to CA Indemnity 2012 (v ) CA Aetn Life Insurnce Compny Pge 8