PARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)

Transcription

1 Your HMO Pln Primry Cre Physicin - You choose Primry Cre Physicin. The Aetn HMO Deductible provider network gives you ccess to wide selection of Primry Cre Physicins ( PCP's) nd Specilists in the stte. Your PCP will coordinte your cre nd provide referrls to other prticipting helth cre professionls. Prescription Drugs Preventive Cre Physicin Office Visit PCP Physicin Office Visit Specilist Urgent Cre Centers X-Ry nd Dignostic Lbs Emergency Cre Hospitl Cre Outptient Surgery Home Helth Cre Durble Medicl Equipment Covered t copy, no deductible Covered t $0 copy, no deductible Covered t the PCP copy, no deductible Covered t the Specilist copy, no deductible Covered t copy, no deductible Covered t copy, no deductible Services Covered by Copy Multiple copys will be pplied when multiple services re rendered. The member will be responsible for one copy for ech clinicl service provided. Deductible A deductible is set mount of expenses you py ech yer before your pln begins to py towrd covered services. You will need to meet deductible for: Out of Pocket Mximum The out-of-pocket mximum is limit on the mount you py out of your pocket in given pln yer. This feture protects you from finncil exposure due to ctstrophic helth events. When your eligible out-of-pocket expenses rech the mximum limit, your remining eligible expenses re covered by the HMO pln t 100% for the reminder of the clendr yer. PLAN FEATURES Deductible (per clendr yer) $1,000 Individul $2,000 Fmily Unless otherwise indicted, the Deductible must be met prior to benefits being pyble. Once the Fmily Deductible is met, ll fmily members will be considered s hving met their Deductible for the reminder of the clendr yer. 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. Member Coinsurnce Out-of-Pocket Mximum (per clendr yer) Lifetime Mximum Primry Cre Physicin Selection Referrl Requirements 30% $3,500 Individul $7,000 per Fmily Only those prticipting providers/referred out of pocket expenses resulting from the ppliction of coinsurnce percentge, deductible, nd copys 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. Unlimited except where otherwise indicted. Required Required for ll non-emergency, non-urgent nd non-primry Cre Physicins services, except direct ccess services CA Aetn Life Insurnce Compny Pge 1 of 6

2 PREVENTIVE CARE Routine Adult Physicl Exms/ Immuniztions Limited to 1 exm every 12 months for members ge 18 nd older. Well Child Exms / Immuniztions Provides coverge for 9 exms from birth up to ge 3; 1 exm per 12 months from ge 3 through ge 17. Routine Gynecologicl Cre Exms* Includes Pp smer, HPV screening nd relted lb fees. Direct ccess to prticipting providers. One routine exm per 365 dys, unless otherwise recommended by physicin. 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 (includes routine sigmoidoscopy nd preventive colonoscopy) For ll members 50 nd over. Frequency schedule pplies. Colonoscopy (non-preventive) Routine Eye & Hering Screenings Routine Eye Exms (Refrction)* Limited to 1 exm every 24 months. PHYSICIAN SERVICES Primry Cre Physicin Visits Specilist Office Visits E-Visits - Primry Cre & Specilist Physicins Wlk-In Clinics Pre-Ntl Mternity Mternity - Delivery nd Post-Prtum Cre Allergy Testing & Tretment DIAGNOSTIC PROCEDURES Dignostic Lbortory Dignostic X-ry Complex Imging URGENT MEDICAL CARE Urgent Cre (benefit vilbility my vry by loction) MENTAL HEALTH SERVICES Outptient Serious Mentl Illness or Biologiclly bsed Mentl illness See Outptient Surgery Benefit Pid s prt of routine physicl exm. $40 copy, deductible wived $40 copy, deductible wived $40 copy, deductible wived $40 copy, deductible wived $40 copy, deductible wived $40 copy, deductible wived $100 copy, deductible wived $50 copy, deductible wived $40 copy per visit, deductible wived CA Aetn Life Insurnce Compny Pge 2 of 6

3 Outptient Other thn Serious mentl Illness $40 copy per visit, deductible wived or Biologiclly Bsed Mentl Illness Limited to 20 visits per clendr yer ALCOHOL/DRUG ABUSE SERVICES Outptient Detoxifiction $40 copy per visit, deductible wived Outptient Rehbilittion OTHER SERVICES Outptient Rehbilittion Therpy $40 per visit copy, deductible wived Includes physicl nd occuptionl therpy. Limited to 20 visits per member per clendr yer. Limits do not pply to utism Outptient Speech Therpy Limited to 20 visits per clendr yer. Limits do not pply to utism. Outptient Physicl nd Occuptionl Therpy Limited to 20 visits per clendr yer combined. Limits do not pply to utism. Subluxtion (Chiroprctic)* Limited to 20 visits per clendr yer Infusion Therpy - Home or Physicin's Office Infusion Therpy - OP Fcility Dibetic Supplies Fmily Plnning Infertility Tretment Dignosis nd tretment of the underlying medicl condition Voluntry Steriliztion - Vsectomy Voluntry Steriliztion - Tubl Ligtion $40 per visit copy, deductible wived $40 per visit copy, deductible wived $15 per visit copy, deductible wived $40 per visit copy, deductible wived $40 per visit copy, deductible wived Phrmcy cost shring pplies if Phrmcy coverge is included; otherwise PCP office visit cost shring pplies 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. EMERGENCY MEDICAL CARE Emergency Room Ambulnce HOSPITAL CARE Inptient Coverge Inptient Mternity Coverge Outptient Surgery in Hospitl Outptient Surgery in Free-Stnding Surgery Center MENTAL HEALTH SERVICES Inptient Severe Mentl Illness or Biologiclly Bsed Mentl Illness Inptient Other thn Severe Mentl Illness or Biologiclly Bsed Mentl Illness ALCOHOL/DRUG ABUSE SERVICES Inptient Detoxifiction Inptient Rehbilittion $150 copy fter deductible $100 copy fter deductible CA Aetn Life Insurnce Compny Pge 3 of 6

4 OTHER SERVICES Autism Tretment Skilled Nursing Fcility Limited to 100 dys per clendr yer Home Helth Cre Limited to 100 visits per clendr yer Hospice Cre - Inptient Hospice Cre - Outptient Durble Medicl Equipment Mximum benefit of $2,000 per member per clendr yer. Limit does not pply to prosthetics or orthotics. Britric Surgery Trnsplnts PHARMACY - PRESCRIPTION DRUG BENEFITS Retil Up to 30-dy supply Mil Order Up to 90-dy supply Member cost shring is bsed on the type of service performed nd the plce rendered. $40 copy fter deductible $40 copy per visit fter deductible 50% of the cost of the item (of contrcted rte), fter deductible $20 copy for generic drugs, $40 copy for formulry brndnme drugs, nd $60 copy for non-formulry brnd-nme drugs up to 30 dy supply t prticipting phrmcies 2x retil 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 nd the brnd price. Pln includes lifestyle/performnce drugs (limited to 4 pills per month), contrceptive drugs, devices obtinble from phrmcy nd dibetic supplies. Precertifiction nd step-therpy included. Formulry generic FDA-pproved Women s Contrceptives covered 100% in network. *Members my directly ccess prticipting providers for certin services s outlined in the pln documents. Wht's Aetn is the brnd nme used for products nd services provided by one or more of the Aetn group of subsidiry compnies. The Aetn compnies tht offer, underwrite or dminister benefits include Aetn Helth Inc.. While this mteril is believed to be ccurte s of the print dte, it is subject to chnge. 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 or rider(s) purchsed CA Aetn Life Insurnce Compny Pge 4 of 6

5 All medicl nd hospitl services not specificlly covered in, or which re limited or excluded by your pln documents, including costs of services before coverge begins nd fter coverge termintes. Cosmetic surgery. Custodil cre. Dentl cre nd dentl x-rys. Donor egg retrievl. 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 Implntble drugs nd certin injectble drugs including injectble infertility drugs. 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. Nonmediclly necessry services or supplies. Outptient prescription drugs (except for tretment of dibetes), unless covered by prescription pln rider nd over-the-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. Specil duty nursing. Therpy or rehbilittion other thn those listed s covered in the pln documents. 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 ny results or outcomes. Consult the pln document (i.e. Schedule of Benefits, Certificte of Coverge, Evidence of Coverge, Group Agreement, Group Insurnce Certificte nd/or Group Policy) to determine governing contrctul provisions, including procedures, exclusions nd limittions relting to the pln. The vilbility of pln or progrm my vry by geogrphic service re. Some benefits re subject to limittions or visit mximums. With the exception of Aetn Rx Home Delivery, ll prticipting physicins, hospitls nd other helth cre providers re independent contrctors nd re neither gents nor employees of Aetn. The vilbility of ny prticulr provider cnnot be gurnteed, nd provider network composition is subject to chnge. Notice of the chnge shll be provided in ccordnce with pplicble stte lw. Aetn Phrmcy Mngement refers to n internl business unit of Aetn Helth Mngement, LLC. 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 or the Aetn Mediction Formulry Guide. Mny drugs, including mny of those listed on the formulry, re subject to rebte rrngements between Aetn nd the mnufcturer of the drugs. Rebtes received by Aetn from drug mnufcturers re not reflected in the cost pid by member for prescription drug. 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. 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 milorder phrmcy services CA Aetn Life Insurnce Compny Pge 5 of 6

6 Certin primry cre providers re ffilited with integrted delivery systems or other provider groups (such s independent prctice ssocitions nd physicin-hospitl orgniztions), nd members who select these providers will generlly be referred to specilists nd hospitls within those systems or groups. However, if system or group does not include provider qulified to meet member's medicl needs, member my request to hve services provided by non-system or non-group providers. Member's request will be reviewed nd will require prior uthoriztion from the system or group nd/or Aetn to be covered benefit. 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 obtins covered services from prticipting providers, the provider will obtin precertifiction. If the Member obtins covered services from nonprticipting provider, the Member must obtin the precertifiction. Precertifiction requirements my vry. Members my refer to their pln documents for complete list of medicl services tht require precertifiction. Certin benefits like comprehensive infertility nd dvnced reproductive technology (ART) services, if covered under your pln, re subject to select network of prticipting providers, from which you will be required to seek cre to receive covered benefits. Members or providers my be required to precertify, or obtin prior pprovl of coverge for certin services such s nonemergency inptient hospitl cre. Certin benefits like comprehensive infertility nd dvnced reproduction technology (ART) services, if covered under your pln, re subject to select network of prticipting providers, from which you will be required to seek cre to receive covered benefits. While this informtion is believed to be ccurte s of the print dte, it is subject to chnge CA Aetn Life Insurnce Compny Pge 6 of 6