| 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) |
|
$14,500 maximum per 24 months, inpatient and outpatient combined. Limit excludes detox unless admitted to a chemical dependency program where you receive these services. |
| Alcohol/Chemical Dependency Treatment (Outpatient) |
|
$10 copay |
| Allergy Testing/Injections, Physician Services |
|
$10 copay per office/clinic visit |
| Ambulance – Air, Emergency Medical Care |
|
$100 copay |
| Ambulance – Ground, Emergency Medical Care |
|
$75 copay |
| Chemical/Alcohol Dependency (Inpatient) |
|
$14,500 maximum per 24 months, inpatient and outpatient combined. Limit excludes detox unless admitted to a chemical dependency program where you receive these services. |
| Chemical/Alcohol Dependency (Outpatient) |
|
$10 copay |
| Clinic and Office Visits, Physician Services |
|
$10 copay per office/clinic visit |
| Coinsurance, Member |
|
20% for durable medical equipment |
| Deductible |
|
None |
| Diagnostic Procedures – Diagnostic Laboratory and X-ray – Inpatient |
|
Included in the $10 copay if performed during physician office visit and billed by the physician |
| Diagnostic Procedures – Diagnostic Laboratory and X-ray – Outpatient |
|
$10 copay when performed in an outpatient, hospital or other outpatient facility, including independent lab. |
| Durable Medical Equipment – e.g. rental of wheelchair, walker, cane, insulin |
|
20% coinsurance (May need to be preauthorized) |
| 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 |
|
$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 |
|
$10 copay |
| Eye Exams, Routine, Physician Services |
|
$10 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) |
|
$10 office visit copay for services performed in doctor's office.
$100 copay for outpatient surgery.
Inpatient subject to inpatient hospital copay. |
| Glucometer Pump |
|
Glucometers listed as Tier 1 in the Preferred Drug List are free. |
| 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 – maximum of 5 days per 3 months of hospice care) |
|
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 preauthorized) |
| Hospital Care – Outpatient Surgical and Ambulatory Surgical Center Facility |
|
Covered at 100%, after $100 copay; (Must be preauthorized) |
| 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 |
|
$10 copay per office/clinic visit |
| Inpatient Alcohol/Chemical Dependency |
|
$14,500 maximum per 24 months, inpatient and outpatient combined. Limit excludes detox unless admitted to a chemical dependency program where you receive these services. |
| Inpatient, Diagnostic Laboratory and X-ray, Diagnostic Procedures |
|
Included in the $10 copay if performed during physician office visit and billed by the physician |
| Inpatient, Hospital Care |
|
Covered at 100%, after $200 copay per day, $600 maximum per calendar year;
(Must be preauthorized) |
| 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 preauthorized) |
| Inpatient, Mental Health Services |
|
Subject to inpatient hospital copay |
| 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 |
|
$10 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 |
|
$10 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 |
|
$10 copay, limited to 50 visits per calendar year |
| Non-emergency care in an Emergency Room, Emergency Medical Care |
|
Not Covered |
| Obesity Surgery |
|
|
| Office and Clinic Visits, Physician Services |
|
$10 copay per office/clinic visit |
| Out-of-Pocket Maximum (per calendar year) |
|
$750 Individual/
$1,500 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 |
|
$10 copay |
| Outpatient – Diagnostic Laboratory and X-ray, Diagnostic Procedures |
|
$10 copay when performed in an outpatient, hospital or other outpatient facility, including independent lab. |
| Outpatient, Hospice Care (Includes respite, care – maximum of 5 days per 3 months of hospice care) |
|
Covered at 100% |
| Outpatient, Hospital Expenses (excluding surgery) |
|
Covered at 100%;
(Must be preauthorized) |
| Outpatient, Mental Health Services |
|
$10 copay, limited to 50 visits per calendar year |
| Outpatient, Short-Term Rehabilitation |
|
$10 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 preauthorized) |
| Pharmacy, Mail-order |
|
Provided by Wellpartner |
| Pharmacy, Retail |
|
|
| Physician Services, Allergy Testing/Injections |
|
$10 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 |
|
$10 copay for the initial diagnosis visit only; all additional visits covered at 100% |
| Physician Services, Office and Clinic Visits |
|
$10 copay per office/clinic visit |
| Physician Services, Prostate-specific Antigen Tests |
|
$10 office copay;
Covered as medical (not preventive); as recommended by provider |
| Physician Services, Vision Eyewear |
|
Maximum plan payment of $150 every 24 months
|
| Physician Services, Routine Eye Exams |
|
$10 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 |
|
$10 office visit copay
Covered as medical (not preventive); as recommended by provider |
| Retail, Pharmacy |
|
|
| Routine Adult Physical Exams and Preventive Immunizations, Preventive Care, |
|
Covered at 100%, not subject to copay |
| Routine Eye Exams, Physician Services |
|
$10 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 |
|
$10 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 preauthorized. Maximum of 150 days per year |
| Smoking Cessation |
|
Covered at 100% |
| Spinal Disorders |
|
$10 copay;
Spinal and extremity manipulations performed by an MD, DO, chiropractor or therapist. Limited to 10 visits per calendar year. |
| Temporomandibular Joint Dysfunction (TMJ) |
|
Covers medical in nature surgical treatment only if preauthorized (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 |
|
$10 copay |
| Vision Eyewear, Physician Services |
|
Maximum plan payment of $150 every 24 months |
| Voluntary Sterilization, Family Planning (Including tubal ligation and vasectomy.Excludes reversals) |
|
$10 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
|
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.
