Page 9 - GLG Benefits Guide
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Summary of Medical Beneits
Aetna PPO 500
Plan Features In-Network Out-of-Network
Calendar Year Deductible (the amount you must pay before the plan $500 Individual $2,500 Individual
starts paying beneits; excludes copays) $1,000 Family $5,000 Family
Calendar Year Out-of-Pocket Maximum (includes copay, deductible $2,500 Individual $5,000 Individual
and coinsurance) $5,000 Family $10,000 Family
Lifetime Maximum Unlimited
Doctors’ Ofice Visits\
> Primary Care Physician (PCP) Deductible then $25 copay 60% after deductible
> Telemedicine 100% after deductible
> Specialist Deductible then $50 copay
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) Deductible then $25 copay 60% after deductible
Maternity
> Visit to conirm Pregnancy Deductible then $25 copay 60% after deductible
> Specialist Visit Deductible then $50 copay
> Prenatal, Delivery and Postnatal* 90% after deductible
Hospital—Inpatient Stay 90% after deductible 60% after deductible**
Outpatient Surgery 90% after deductible 60% after deductible**
Diagnostic test (x-ray, blood work) 90% after deductible 60% after deductible
Imaging (CT/PET scans, MRIs) 90% after deductible
Emergency Care
> Emergency Health Services Deductible then $200 copay Deductible then $200 copay†
> Urgent Care Facility*** Deductible then $75 copay 60% after deductible
> Ambulance Services—Emergency only 90% after deductible 90% after deductible
Infertility Services †† 90% after deductible 60% after deductible
Mental Health and Substance Abuse Services—Outpatient Deductible then $25 copay 60% after deductible**
Mental Health and Substance Abuse Services—Inpatient and 90% after deductible 60% after deductible**
Intermediate
Acupuncture (100 visits per year per member) Deductible then $25 copay 60% after deductible
Prescription Drugs (not subject to deductible)
Retail (30-day supply)
> Tier 1/Tier 2/Tier 3 $10/$30/$60 20% of submitted cost; after
Mail Order (90-day supply) applicable copay
> Tier 1/Tier 2/Tier 3 $25/$75/$150 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.
† Prior authorization is required if results in an inpatient stay.
†† 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 (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
HR Support for speciic terms and conditions, including limitations and exclusions.
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Aetna PPO 500
Plan Features In-Network Out-of-Network
Calendar Year Deductible (the amount you must pay before the plan $500 Individual $2,500 Individual
starts paying beneits; excludes copays) $1,000 Family $5,000 Family
Calendar Year Out-of-Pocket Maximum (includes copay, deductible $2,500 Individual $5,000 Individual
and coinsurance) $5,000 Family $10,000 Family
Lifetime Maximum Unlimited
Doctors’ Ofice Visits\
> Primary Care Physician (PCP) Deductible then $25 copay 60% after deductible
> Telemedicine 100% after deductible
> Specialist Deductible then $50 copay
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) Deductible then $25 copay 60% after deductible
Maternity
> Visit to conirm Pregnancy Deductible then $25 copay 60% after deductible
> Specialist Visit Deductible then $50 copay
> Prenatal, Delivery and Postnatal* 90% after deductible
Hospital—Inpatient Stay 90% after deductible 60% after deductible**
Outpatient Surgery 90% after deductible 60% after deductible**
Diagnostic test (x-ray, blood work) 90% after deductible 60% after deductible
Imaging (CT/PET scans, MRIs) 90% after deductible
Emergency Care
> Emergency Health Services Deductible then $200 copay Deductible then $200 copay†
> Urgent Care Facility*** Deductible then $75 copay 60% after deductible
> Ambulance Services—Emergency only 90% after deductible 90% after deductible
Infertility Services †† 90% after deductible 60% after deductible
Mental Health and Substance Abuse Services—Outpatient Deductible then $25 copay 60% after deductible**
Mental Health and Substance Abuse Services—Inpatient and 90% after deductible 60% after deductible**
Intermediate
Acupuncture (100 visits per year per member) Deductible then $25 copay 60% after deductible
Prescription Drugs (not subject to deductible)
Retail (30-day supply)
> Tier 1/Tier 2/Tier 3 $10/$30/$60 20% of submitted cost; after
Mail Order (90-day supply) applicable copay
> Tier 1/Tier 2/Tier 3 $25/$75/$150 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.
† Prior authorization is required if results in an inpatient stay.
†† 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 (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
HR Support for speciic terms and conditions, including limitations and exclusions.
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