|
PPO Medical Plan - Aetna Health Fund
July 1,
2008 -
June 30, 2009 |
|
Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
|
|
|
In-Network |
Out-Of-Network |
|
PPO
Network |
Preferred Providers |
Non-Preferred
Providers |
|
Health
Fund Allotment |
Eligible expenses are paid
through the health fund and the member's deductible
and fund balance are simultaneously reduced.
Fund allotment is $750/Individual and $1,500
Family. One family member can utilize the
$1,500. Account is to be used for covered
out-of-pocket expenses with unused dollars carried
over to next year's account balance (subject to
continued enrollment in the Aetna Health Fund
product.) |
|
Deductible |
$2,000 Individual
$6,000 Family |
$4,000 Individual
$12,000 Family |
|
Coinsurance |
80%
after deductible |
60%
after deductible |
|
Out-of-Pocket Maximum/Yr* |
$5,000 Individual
$15,000 Family |
$10,000 Individual
$30,000 Family |
|
Lifetime Maximum
Benefit |
Unlimited except where
otherwise indicated |
|
Office
Visits - Specialist |
80% after deductible |
60%
after deductible |
|
Office
Visits - Non Specialist |
80% after deductible |
60%
after deductible |
|
Immunizations - 7 exams to age 1, 2 exams from
13-24 months, 1 exam per 12 months to age 18 |
100%,
deductible waived |
60%
after deductible |
|
Routine
Adult
Physicals - One annual exam |
100%,
deductible waived |
60%
after deductible |
|
Diagnostic Lab & X-ray |
80% after deductible |
60% after deductible |
|
Ambulance |
80% after deductible |
|
Hospital Inpatient** |
80% after deductible |
60% after deductible |
|
Emergency
Room |
80% after deductible |
|
Urgent
Care |
80% after deductible |
60%
after deductible |
|
Maternity
|
Paid as any other condition |
|
Spinal
Manipulations - 20 visits/yr |
80% after deductible |
60% after deductible |
|
Rehabilitation Therapy: |
|
|
Inpatient Rehabilitation**
|
80% after deductible |
60% after deductible |
|
Outpatient
Physical, Speech
and
Occupational Therapy
|
80% after deductible |
60% after deductible
|
|
Mental
Health Services: |
|
|
Inpatient** - 30 days/yr
|
80% after deductible |
60% after deductible |
|
Outpatient - 20 visits/yr
|
80% after deductible
|
60% after deductible
|
|
Chemical
Dependency: |
$15,000 max per plan year |
|
Inpatient**
|
80% after deductible |
60% after deductible
|
|
Outpatient
|
80% after deductible
|
60% after deductible
|
|
Prescription
Drugs - Retail
|
100%
after applicable copays
Generic:
$15 Copay
Formulary Brand: $25 Copay
Non Formulary Brand: $40 Copay
|
60%
after applicable copays
Generic:
$15 Copay
Formulary Brand: $25 Copay
Non Formulary Brand: $40 Copay
|
|
RX
Dosages - Retail |
30-day supply |
|
Mail Order Prescriptions
|
Generic:
$30 Copay
Formulary Brand: $50 Copay
Non Formulary Brand: $80 Copay
|
No Coverage |
|
RX
Dosages - Mail Order |
90-day supply |
|
Routine Hearing Exam - one per yr |
100%, deductible waived |
60% after deductible |
|
Routine Vision Exam - one per yr |
100%, deductible waived |
60% after deductible |
|
Vision
Hardware |
$200
every 24 months |
|
Aetna
Vision One Brochure |
Click Here |
