Medical Benefits | Aetna Public Employees Plan

Medical Benefits

Search the 2010 Aetna Public Employees Plan summary below for information about specific benefits. For full details about 2010 benefits, exclusions and your rights as an Aetna enrollee, download the 2010 Certificate of Coverage. If you have questions, call Aetna Member Services at 1-800-222-9205.

View/print user-friendly 2010 Summary of Benefits [PDF]

Quit For Life
(Tobacco Cessation)

Nurse Coaching
For enrollees with congestive heart failure, coronary heart disease or diabetes

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Key Plan Features		In-Network Care
Acupuncture		Covered for treatment of pain or as anesthetic only. Limited to 16 visits per calendar year.
Adult Physical Exams and Preventive Immunizations, Routine, Preventive Care		Covered at 100%, not subject to copay
Alcohol/Chemical Dependency (Inpatient)		Subject to inpatient hospital copay. Must be precertified.
Alcohol/Chemical Dependency Treatment (Outpatient)		$25 copay
Allergy Testing/Injections, Physician Services		$25 copay per office/clinic visit
Ambulance – Air and Water, Emergency Medical Care		$100 copay
Ambulance – Ground, Emergency Medical Care		$75 copay
Chemical/Alcohol Dependency (Inpatient)		Subject to inpatient hospital copay. Must be precertified.
Chemical/Alcohol Dependency (Outpatient)		$25 copay per office/clinic visit.
Clinic and Office Visits, Physician Services		$25 copay per office/clinic visit
Coinsurance, Member		20% for durable medical equipment
Deductible, Medical Benefits		$250 per person, $750 per family
Diagnostic Procedures – Diagnostic Laboratory and X-ray High Cost Imaging		Included in $25 office visit copay when performed at a physician's office. $25 copay, when performed in an outpatient facility, hospital or other outpatient facility setting including an independent lab $25 copay. Must be precertified.
Durable Medical Equipment – e.g. rental of wheelchair, walker, cane, insulin		20% coinsurance, May need to be precertified.
Durable Medical Equipment – Wig or hairpiece to replace hair loss due to Radiation or chemotherapy		20% coinsurance, $100 lifetime maximum
Emergency Medical Care – Ambulance – Air and Water		$100 copay
Emergency Medical Care – Ambulance – Ground		$75 copay
Emergency Medical Care – Emergency Room		$75 copay, Waived if admitted as inpatient
Emergency Medical Care – Non-emergency care in an Emergency Room		Not Covered
Emergency Medical Care – Urgent Care Provider		$25 copay
Eye Exams, Routine, Physician Services		$25 office visit copay; One routine exam per calendar year
Family Planning – Infertility Treatment and Services		Not Covered
Family Planning – Voluntary Sterilization (Including tubal ligation and vasectomy.Excludes reversals)		$25 office visit copay for services performed in doctor's office. $100 copay for outpatient surgery. Inpatient subject to inpatient hospital copay.
Glucometer Pump		Covered under the tier listed in the Preferred Drug List.
Gynecological Care Exams, Routine, Preventive Care		Covered at 100%, not subject to copay; One exam per year
Hearing Aids, Physician Services		Maximum plan payment of $800 every 3 calendar years. Maximum is for hearing aids and rental/repair combined.
Hearing Exams, Routine, Preventive Care		Covered at 100%, no copay; One routine exam per calendar year
Hospice Care – Inpatient		Covered at 100%; after $200 copay per day, $600 maximum per calendar year
Hospice Care – Outpatient (Includes respite care – lifetime maximum of $5,000)		Covered at 100%
Hospital Care – Inpatient Coverage		Covered at 100%, after $200 copay per day, $600 maximum per calendar year; Must be preauthorized.
Hospital Care – Inpatient Maternity Coverage		Subject to inpatient hospital copay
Hospital Care – Outpatient Hospital Expenses (excluding surgery)		Covered at 100%; Must be precertified.
Hospital Care – Outpatient Surgical and Ambulatory Surgical Center Facility		Covered at 100%, after $100 copay; Must be precertified.
Home Health Care – Home Health Care Aide Visit (1 visit = up to 4 hours per visit)		Covered at 100%
Home Health Care – Nurse or Therapist Visit (Each visit = 1 visit)		Covered at 100%
Infertility Treatment and Services, Family Planning		Not Covered
Injections, Allergy Testing, Physician Services		$25 copay per office/clinic visit
Inpatient Alcohol/Chemical Dependency		Subject to inpatient hospital copay. Must be precertified.
Inpatient, Hospital Care		Covered at 100%, after $200 copay per day, $600 maximum per calendar year; Must be precertified.
Inpatient, Maternity, Hospital Care		Subject to inpatient hospital copay
Inpatient Hospice Care		Covered at 100%, after $200 copay per day, $600 maximum per calendar year; Must be precertified.
Inpatient, Mental Health Services		Subject to inpatient hospital copay. Must be precertified.
Lifetime Maximum		No lifetime maximum
Mail-order, Pharmacy		Provided by Wellpartner
Mammograms, Routine, Preventive Care		Covered at 100%; Every 1-3 years beginning at age 40
Massage Therapy		$25 copay; Covered only to treat injury or exacerbation of existing injury. Not covered for maintenance therapy. Limited to 16 visits per calendar year.
Maternity, Inpatient, Hospital Care		Subject to inpatient hospital copay
Maternity – OB Visits, Physician Services		$25 copay for the initial diagnosis visit only; all additional visits covered at 100%
Member Coinsurance		20% for durable medical equipment
Mental Health Services, Inpatient		Subject to inpatient hospital copay
Mental Health Services, Outpatient		$25 copay per office/clinic visit
Non-emergency care in an Emergency Room, Emergency Medical Care		Not Covered
Obesity Surgery		Very limited coverage. See Obesity Surgery page for more information.
Office and Clinic Visits, Physician Services		$25 copay per office/clinic visit
Out-of-Pocket Maximum (per calendar year)		$2000 Individual/ $6,000 Family; Out-of-pocket expenses include office visits and inpatient copays. Emergency Room copays do not apply to the out-of-pocket maximum
Outpatient – Alcohol/Chemical Dependency		$25 copay
Outpatient, Hospice Care (Includes respite, care – lifetime maximum of $5,000)		Covered at 100%
Outpatient, Hospital Expenses (excluding surgery)		Covered at 100%; Must be precertified.
Outpatient, Mental Health Services		$25 copay per office/clinic visit
Outpatient, Short-Term Rehabilitation		$25 office visit copay; Includes Speech, Physical, Occupational, and Neurodevelopmental Therapy. Limited to 60 visits per calendar year combined.
Outpatient Surgical and Ambulatory Surgical Center Facility, Hospital Care		Covered at 100%, after $100 copay; Must be precertified.
Pharmacy, Mail-order		Provided by Wellpartner
Pharmacy, Retail		Provided by Washington State Rx Services. Refer to Prescription Drug Benefits page.
Physician Services, Allergy Testing/Injections		$25 copay per office/clinic visit
Physician Services, Hearing Aids		Maximum plan payment of $800 every 3 calendar years. Maximum is for hearing aids and rental/repair combined.
Physician Services, Maternity OB Visits		$25 copay for the initial diagnosis visit only; all additional visits covered at 100%
Physician Services, Office and Clinic Visits		$25 copay per office/clinic visit
Physician Services, Prostate-specific Antigen Tests		$25 office copay; Covered as medical (not preventive); as recommended by provider
Physician Services, Vision Eyewear		Maximum plan payment of $150 every 24 months. You do not need to use Aetna network providers for costs to be covered.
Physician Services, Routine Eye Exams		$25 office visit copay; One routine exam per calendar year
Preventive Care, Routine Gynecological Care Exams		Covered at 100%, not subject to copay; One exam per year
Preventive Care, Routine Hearing Exams		Covered at 100%, no copay; One routine hearing exam per calendar year
Preventive Care, Routine Mammograms		Covered at 100%; Every 1-3 years beginning at age 40
Preventive Care, Well Child Exam and Preventive Immunizations		Covered at 100%, not subject to copay; 8 exams in the first 24 months of life
Preventive Immunization and Routine Adult Physical Exams, Preventive Care		Covered at 100%, not subject to copay
Preventive Immunizations and Well Child Exam, Preventive Care		Covered at 100%, not subject to copay; 8 exams in the first 24 months of life
Primary Care Physician Selection		No requirement to select a PCP; Must use network providers to obtain benefits.
Private Duty Nurse		Covered at 100%
Prostate-specific Antigen Tests, Physician Services		$25 office visit copay Covered as medical (not preventive); as recommended by provider
Retail, Pharmacy		Provided by Washington State Rx Services. Refer to 2010 Prescription Drug Benefits page.
Routine Adult Physical Exams and Preventive Immunizations, Preventive Care,		Covered at 100%, not subject to copay
Routine Eye Exams, Physician Services		$25 office visit copay; One routine exam per calendar year
Routine Gynecological Care Exams, Preventive Care		Covered at 100%, not subject to copay; One exam per year
Routine Hearing Exams, Preventive Care		Covered at 100%, no copay, 1 routine hearing exam per calendar year
Routine Mammograms, Preventive Care		Covered at 100%; Every 1-3 years beginning at age 40
Routine Well Child Exam and Preventive Immunizations, Preventive Care		Covered at 100%, not subject to copay; 8 exams in the first 24 months of life
Short-Term Rehabilitation, Outpatient		$25 office visit copay; Includes speech, Physical, Occupational, and Neurodevelopmental Therapy. Limited to 60 visits per calendar year combined
Skilled Nursing Facility		Subject to inpatient hospital copay Semi-private room rate. Must meet Medicare’s requirements for skilled nursing and be precertified. Maximum of 150 days per year
Smoking Cessation		Covered at 100%. Limited to Free & Clear tobacco cessation program.
Spinal Disorders		$25 copay; Spinal and extremity manipulations performed by an MD, DO, chiropractor or therapist. Limited to 10 visits per calendar year.
Surgery Inpatient Outpatient		Covered at 100%, after $200 copay per day, $600 maximum per calendar year; Must be precertified $100 copay
Temporomandibular Joint Dysfunction (TMJ)		Covers medical in nature surgical treatment only if precertified; No coverage for non-surgical treatment
Transplants		Covered at 100%; Coverage is provided at an Institute of Excellence facility only
Urgent Care Provider, Emergency Medical Care		$25 copay
Vision Eyewear, Physician Services		Maximum plan payment of $150 every 24 months. You do not need to use Aetna network providers for costs to be covered.
Voluntary Sterilization, Family Planning (Including tubal ligation and vasectomy.Excludes reversals)		$25 office visit copay for services performed in doctor's office. $100 copay for outpatient surgery. Subject to inpatient hospital copay.
Well Child Exam and Preventive Immunizations, Routine, Preventive Care		Covered at 100%, not subject to copay. 8 exams in the first 24 months of life

Disclaimers
This plan does not cover all health care expenses; some expenses are excluded from coverage or have limits. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.

All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. All preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates.

Some benefits are subject to limitations or visit maximums. Certain services require precertification or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member's preferred provider is coordinating care, the preferred provider will obtain the precertification. Services provided by non-network providers are not covered, except for emergency care. Precertification requirements may vary.

While this information is believed to be accurate as of the print date, it is subject to change. Plans are provided by Aetna Life Insurance Company.

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