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MEDICAL
Q:
What
type of medical plan is provided by my employer?
A:
Quarry Tile provides an
Aetna
Health Fund PPO medical plan for the employees and
their eligible dependents. A "PPO" plan utilizes a
network of "Preferred Providers." Generally, services
received from Preferred Providers will be covered at a higher
benefit level than services of a non-Preferred Provider.
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Q:
Who is eligible?
A:
Generally, all employees who regularly work
35 hours per
week are eligible for coverage the first of the month
following six months of employment. Once eligible, you may also
enroll your spouse and/or your unmarried dependent children
who are under the age of 24 and primarily dependent on you for financial
support.
Q:
When does coverage take effect?
A:
Coverage is
effective the 1st
of the month following 180 days.
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Q:
Are pre-existing conditions covered?
A:
As long
as you had
3 months of continuous, creditable medical insurance prior to
enrolling in the Aetna PPO plan, your
pre-existing conditions will be covered according to plan
provisions. Continuous coverage means that there was not a
lapse of more than 63 days, not counting your 180 day
probationary period, immediately prior to your enrollment in
the plan.
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Q:
How do you receive care?
A:
You will maximize your benefits by utilizing
"Participating" Providers, specific to the plan you have selected.
Simply present your I.D. card, and these
"Participating" providers will
submit the claims for you. A listing of these
"Participating" providers is
available
online.
Q:
What
happens if a provider will not accept my card?
A:
This usually means that the provider is non-participating with
the plan you have selected and therefore your benefits may be
less. It also means that you may need to obtain from the
provider and submit an itemized bill yourself to Aetna, with an accompanying
claim form.
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Q: Is
pre-approval required under our plan?
A:
Prior
authorization is generally required for all inpatient hospital
admissions. In
emergency situations, you or your representative must notify
Aetna
by the end of the next working day
following admission.
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Q: Do
I need a "referral" to see a specialist?
A:
No, you do not need referrals for either in-network or out-of-network
benefits.
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Q:
Are
naturopaths or acupuncturists covered?
A: Acupuncturists and Naturopaths are covered providers to the same extent and subject to the same
limitations as services provided by any other participating or
non-participating provider.
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Q: Is routine preventive
care covered?
A:
In-Network routine
preventive care exams are covered in full.
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Q:
How are prescription drugs covered?
A:
Generic
drugs are covered subject to a $15 copay, and formulary Brand Name
drugs are subject to a $25 copay. Non formulary brand
name drugs are subject to a $40 copay. Each prescription shall
not exceed a 30-day supply. There is no coverage for
prescriptions filled out-of-network.
Mail
order prescriptions are also available subject to a $30 copay
for Generic, and a $50 copay for Brand Name. Non
formulary brand name drugs are subject to a $80 copay.
Each prescription shall not exceed a 90-day supply.
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Q:
Are
contraceptives covered?
A: Yes, contraceptives are
covered under the prescription drug plan.
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Q: What
is not covered under my medical plan?
A:
Please refer to the "Exclusions" section of your Benefit Booklet for details.
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Q:
How
do I confirm that a certain procedure is covered?
A:
If the answer is not clear after reviewing your Benefit
Booklet, please contact the appropriate
Customer
Service Department to confirm coverage.
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Q:
Who
can answer questions?
A:
If
you have a claims question, please contact the appropriate
Customer
Service Department.
Q: In what situations are claim forms required?
A:
Claim forms
will
be required when you must submit the bills yourself, usually with
non-participating providers.
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Q:
Do I have coverage out of the area?
A:
Your
Aetna coverage is nationwide, however benefits are covered at
the out-of-network level.
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DENTAL
Q:
Is
pre-determination necessary for dental coverage?
A:
A
treatment plan should be submitted by your dentist to Aetna prior to extensive procedures being performed.
This will allow you to know in advance what procedures are
covered, the amount Aetna will pay toward the treatment, and your
financial responsibility.
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Q:
Is
orthodontia
covered?
A:
Orthodontia is
not covered through the Aetna plan. Please see your Benefit Booklet for a listing of
covered dental services, exclusions and limitations.
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Q:
Are there
waiting periods under our dental plan?
A:
There are no
waiting periods for Dental Services, as long as you enroll in
the plan within 30 days of your initial eligibility date.
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