Aetna POS II Option 2015

Diocese of Bridgeport
Effective Date: 01-01-2015
Aetna Choice™ POS ll - ASC
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES
PREFERRED CARE
NON-PREFERRED CARE
Employee
Employee
$2,500
$2,500
Deductible (per calendar year)
Family
Family
$5,000
$5,000
Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
Please note that there are incentives that can be earned for deductible credit. Incentives Include the below and begin on
December 1, 2014 and are available through November 30th, 2015.
$400 for taking the Health Assessment (available to all members over 18 years of age)
$400 for having a Routine Physical (available to all members over 18 years of age)
$400 for participating with the Quest Biometric Screening Program (available to all members over 18 years of age)
$200 for participating with a Registered Nurse in Disease Management (available to all members over 18 years of age)
The Maximum reward amount is $800 for an Employee and $1,600 for a Family
Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the
calendar year.
Member Coinsurance
20%, after deductible
50%, after deductible
Applies to all expenses unless otherwise stated.
Employee
Employee
$5,000
$5,000
Member Payment Limit (per calendar year)
$10,000 Family
$12,000 Family
Certain member cost sharing elements may not apply toward the Payment Limit.
Only those expenses resulting from the application of coinsurance percentage, deductible, and all copays may be used to
satisfy the Payment Limit. Amounts over R&C are member's responsibility. Excludes precert penalties.
Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder
of the calendar year.
Lifetime Maximum
None
None
Primary Care Physician Selection
Not required
Not applicable
Certification Requirements Certification for certain types of Non-Preferred 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,
Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $400 per
occurrence.
Precertification for certain procedures/treatments - excluded amount is $200 per occurrence.
Referral Requirement
None
None
PREVENTIVE CARE
PREFERRED CARE
NON-PREFERRED CARE
Covered 100% , deductible & copay 50%, after deductible
Routine Adult Physical Exams/
waived
Immunizations-1 per 12 months
Covered 100% , deductible & copay 50%, after deductible
Routine Well Child Exams/Immunizations
waived
Covered 100% , deductible & copay 50%, after deductible
Routine Gynecological Care Exams
waived
1 per 12 months
Includes Pap smear and related lab fees
Covered 100% , deductible & copay 50%, after deductible
Mammograms (includes Ultrasounds for
Breast Cancer Detection)- 1 per 12 months waived
For covered females age 40 and over.
Routine Digital Rectal Exam / Prostatespecific Antigen Test
For covered males age 40 and over. 1 per 12
months
Colorectal Cancer Screening. Includes
colonoscopies and endoscopies.
Covered 100% , deductible & copay
waived
50%, after deductible
Covered 100% , deductible & copay
waived
50%, after deductible
Testing - Hepatitis A, B, C, HIV, TB
Covered 100%; deductible waived
50% after deductible
Routine Eye Exams
Covered 100% , deductible & copay
waived
50%, after deductible
Covered 100% , deductible & copay
waived
50%, after deductible
1 routine exam per 24 months
Routine Hearing Exams
1 routine exam per 24 months
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Diocese of Bridgeport
Effective Date: 01-01-2015
Aetna Choice™ POS ll - ASC
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PHYSICIAN SERVICES
PREFERRED CARE
NON-PREFERRED CARE
$35 office visit copay; deductible
50%, after deductible
Office Visits to PCP
waived
Includes services of an internist, general physician, family practitioner or pediatrician.
$50 office visit copay; deductible
50%, after deductible
Specialist Office Visits
waived
Covered same as Specialist Office
50%, after deductible
Maternity OB Visits
Visit for initial visit only; thereafter
covered 100%
Covered as either PCP or specialist
50%, after deductible
Allergy Testing
office visit
Covered as either PCP or specialist
50%, after deductible
Allergy Injections (Copay waived when an
office visit
office visit charge is not made)
DIAGNOSTIC PROCEDURES
PREFERRED CARE
NON-PREFERRED CARE
$35 copay; deductible waived
50%, after deductible
Diagnostic Laboratory and X-ray
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable
physician's office visit member cost sharing. If performed in physician's office without an office visit, no copay is charged.
EMERGENCY MEDICAL CARE
PREFERRED CARE
NON-PREFERRED CARE
$75 copay; deductible waived
50%, after deductible
Urgent Care Provider
(benefit availability may vary by location)
Non-Urgent Use of Urgent Care Provider
Not Covered
Not Covered
$150 copay, then 20%; after
Covered same as preferred care
Emergency Room-waived if admitted
deductible
Not Covered
Not Covered
Non-Emergency care in an Emergency
Room
20% after deductible
Covered same as preferred care
Ambulance
HOSPITAL CARE
PREFERRED CARE
NON-PREFERRED CARE
20% after deductible
50%, after deductible
Inpatient Coverage
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
20% after deductible
50%, after deductible
Inpatient Maternity Coverage
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
20% coins after deductible. Routine
50%, after deductible
Outpatient Hospital Expenses (including
colonoscopies covered at 100%
surgery)
The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit
MENTAL HEALTH SERVICES
PREFERRED CARE
NON-PREFERRED CARE
20% after deductible
50%, after deductible
Inpatient
Unlimited days per calendar year.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
$50 office visit copay; deductible
50%, after deductible
Outpatient
waived
Unlimited visits per calendar year.
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
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Diocese of Bridgeport
Effective Date: 01-01-2015
Aetna Choice™ POS ll - ASC
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
ALCOHOL/DRUG ABUSE SERVICES
PREFERRED CARE
NON-PREFERRED CARE
20% after deductible
50%, after deductible
Inpatient
Unlimited visits per calendar year.
Outpatient
$50 office visit copay; deductible
waived
50%, after deductible
Unlimited visits per calendar year.
The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit
OTHER SERVICES
PREFERRED CARE
NON-PREFERRED CARE
20% after plan deductible
50%, after deductible
Convalescent Facility
Limited to 100 days per calendar year.
The member cost sharing applies to all covered benefits incurring during a member's inpatient stay
20% after plan deductible
50%, after deductible
Home Health Care
Unlimited visits per year. Includes Private Duty Nursing.
Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit.
20% after plan deductible
50%, after deductible
Hospice Care - Inpatient
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
20% after plan deductible
50%, after deductible
Hospice Care - Outpatient
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
$50 copay; deductible waived
50%, after deductible
Outpatient Short-Term Rehabilitation
Includes Speech, Physical, Occupational, and Spinal Manipulation Therapy, limited to 60 visits per calendar year.
20% after plan deductible
50%, after deductible
Durable Medical Equipment
Diabetic Supplies
20% after plan deductible
50%, after deductible
Transplants
20% after deductible. Preferred
coverage is provided at an IOE
contracted facility only
50%, after deductible; Non-Preferred
coverage is provided at a Non-IOE
facility.
Mouth, Jaws and Teeth
(oral surgery procedures, whether medical or
dental in nature)
Out of Area Employees & Dependents
20% after deductible
50%, after deductible
Coverage provided at the non-preferred benefit level of the plan.
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Diocese of Bridgeport
Effective Date: 01-01-2015
Aetna Choice™ POS ll - ASC
PHARMACY
Retail
Mail Order
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PREFERRED CARE
NON-PREFERRED CARE
$15 flat copay for generic drugs, 20% 50%, after deductible
coinsurance for formulary brand-name
drugs, and 40% coinsurance for nonformulary brand-name drugs up to a
30 day supply at participating
pharmacies. Minimum copays of
$25/$40, max copays $50/$80.
Flat $30 copay for generic drugs, 20%
coinsurance for formulary brand-name
drugs, and 40% coinsurance for nonformulary brand-name drugs up to a
90 day supply at participating
pharmacies. Minimum copays of
$50/$80, max copays $100/$160.
Not applicable
Diabetic Supplies Rider-Covered 100% at Retail Pharmacies, no copay
Pharmacy Managed Self Injectables (PMSI)
First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy®
Aetna Healthy Actions for Pharmacy - Certain Generic Preventive Medications are covered at 100% and certain formulary
brand name Preventive Medications will get a 50% reduction in cost. Drug Classes included Inhaled Steroids, Anti-Diabetic
Agents, Beta Blockers, Anti-Hypertensives, and Anti-Hyperlipidemics. Please contact HR for a complete listing of drugs that
are eligible
Spouse, children from birth to age 26
Dependents Eligibility
On effective date: Waived for dependent children to age 19
Pre-existing Conditions Rule
After effective date: Waived for dependent children to age 19
This plan does not cover all health care expenses and includes exclusions and limitations. 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.
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. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent
contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC,
is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition
is subject to change without notice.
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. When the member
utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending
on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under
plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed
formulary.
They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and
Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not
available for them. 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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