Page 10 - GLG Benefits Guide
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Summary of Medical Beneits (continued)
Aetna HSA 1400
Plan Features In-Network Out-of-Network
Calendar Year Deductible
(the amount you must pay before the plan starts paying beneits, $1,400 Individual $2,800 Individual
includes medical and pharmacy) $2,800 Family $5,600 Family
No one in the family is eligible for beneits until the family coverage
deductible is met
Calendar Year Out-of-Pocket Maximum $2,500 Individual $5,000 Individual
(Medical and Pharmacy; Includes copay, deductible and coinsurance) $5,000 Family $10,000 Family
If more than one person in a family is covered under the policy, the
single out-of-pocket maximum stated above does not apply
Lifetime Maximum Unlimited
Doctors’ Ofice Visits
> Primary Care Physician (PCP) 80% after deductible
> Telemedicine 100% after deductible 60% after deductible
> Specialist 80% after deductible
Preventive Care (well-baby, well-child, adult and well-woman: 100%, 60% after deductible
including immunizations) Deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year per member) 80% after deductible 60% after deductible
Maternity
> Visit to Conirm Pregnancy
> Specialist Visit 80% after deductible 60% after deductible
> Prenatal, Delivery and Postnatal*
Hospital—Inpatient Stay 80% after deductible 60% after deductible **
Outpatient Surgery 80% after deductible 60% after deductible**
Emergency Care
> Emergency Health Services 80% after deductible
> Urgent Care*** 80% after deductible 60% after deductible
> Ambulance Services—Emergency Only 80% after deductible
Infertility Services †† 80% after deductible 60% after deductible
Mental Health and Substance Abuse Services—Outpatient 80% after deductible 60% after deductible**
Mental Health and Substance Abuse Services—Inpatient and 80% after deductible 60% after deductible**
Intermediate
Acupuncture (100 visits per year per member) 80% after deductible 60% after deductible
Prescription Drugs
Retail (30-day supply) Deductible then 20% of submitted
> Tier 1/Tier 2/Tier 3 Deductible then $10/$30/$60 cost; after applicable copay
Mail Order (90-day supply)
> Tier 1/Tier 2/Tier 3 Deductible then $25/$75/$125 Not applicable
* Notiication is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
** Prior authorization is required.
*** Members can access CVS MinuteClinic for no cost, after deductible is met.
†† Diagnosis and treatment of the underlying medical condition only. Coverage includes artiicial insemination and ovulation induction limited to six courses of
treatment combined, per member lifetime. ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer
(GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Limited to $25,000 in member’s lifetime. Lifetime maximum
applies to all procedures covered by any of our plans except where prohibited by law. Additional coverage for embryo and sperm cryopreservation or storage of
cryopreserved embryos and sperm for all members.
Certain preventive medications will be provided at no cost (deductible and copay waived).
Note: This medical plan summary provides only highlights of these beneits. Please refer to the oficial plan documents or Summary Plan Description, or contact
your People Team Representative for speciic terms and conditions, including limitations and exclusions.
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Aetna HSA 1400
Plan Features In-Network Out-of-Network
Calendar Year Deductible
(the amount you must pay before the plan starts paying beneits, $1,400 Individual $2,800 Individual
includes medical and pharmacy) $2,800 Family $5,600 Family
No one in the family is eligible for beneits until the family coverage
deductible is met
Calendar Year Out-of-Pocket Maximum $2,500 Individual $5,000 Individual
(Medical and Pharmacy; Includes copay, deductible and coinsurance) $5,000 Family $10,000 Family
If more than one person in a family is covered under the policy, the
single out-of-pocket maximum stated above does not apply
Lifetime Maximum Unlimited
Doctors’ Ofice Visits
> Primary Care Physician (PCP) 80% after deductible
> Telemedicine 100% after deductible 60% after deductible
> Specialist 80% after deductible
Preventive Care (well-baby, well-child, adult and well-woman: 100%, 60% after deductible
including immunizations) Deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year per member) 80% after deductible 60% after deductible
Maternity
> Visit to Conirm Pregnancy
> Specialist Visit 80% after deductible 60% after deductible
> Prenatal, Delivery and Postnatal*
Hospital—Inpatient Stay 80% after deductible 60% after deductible **
Outpatient Surgery 80% after deductible 60% after deductible**
Emergency Care
> Emergency Health Services 80% after deductible
> Urgent Care*** 80% after deductible 60% after deductible
> Ambulance Services—Emergency Only 80% after deductible
Infertility Services †† 80% after deductible 60% after deductible
Mental Health and Substance Abuse Services—Outpatient 80% after deductible 60% after deductible**
Mental Health and Substance Abuse Services—Inpatient and 80% after deductible 60% after deductible**
Intermediate
Acupuncture (100 visits per year per member) 80% after deductible 60% after deductible
Prescription Drugs
Retail (30-day supply) Deductible then 20% of submitted
> Tier 1/Tier 2/Tier 3 Deductible then $10/$30/$60 cost; after applicable copay
Mail Order (90-day supply)
> Tier 1/Tier 2/Tier 3 Deductible then $25/$75/$125 Not applicable
* Notiication is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
** Prior authorization is required.
*** Members can access CVS MinuteClinic for no cost, after deductible is met.
†† Diagnosis and treatment of the underlying medical condition only. Coverage includes artiicial insemination and ovulation induction limited to six courses of
treatment combined, per member lifetime. ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer
(GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Limited to $25,000 in member’s lifetime. Lifetime maximum
applies to all procedures covered by any of our plans except where prohibited by law. Additional coverage for embryo and sperm cryopreservation or storage of
cryopreserved embryos and sperm for all members.
Certain preventive medications will be provided at no cost (deductible and copay waived).
Note: This medical plan summary provides only highlights of these beneits. Please refer to the oficial plan documents or Summary Plan Description, or contact
your People Team Representative for speciic terms and conditions, including limitations and exclusions.
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