Page 10 - GLG 2021 Annual Benefits
P. 10
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 $3,000 Individual $6,000 Individual
(Medical and Pharmacy; Includes copay, deductible, and coinsurance) $6,000 Family $12,000 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
> General Medicine Virtual Visits**** 100% after deductible 60% after deductible
> Specialist 80% after deductible
Preventive Care (well-baby, well-child, and well-adult; including 100%, 60% after deductible
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
Gender Reassignment***** 90% 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 Deductible then 60% of
Retail (30-day supply) submitted cost; after applicable
> Tier 1/Tier 2/Tier 3 Deductible then $10/$30/$60
Mail Order (90-day supply) copay
> Tier 1/Tier 2/Tier 3 Deductible then $25/$75/$125 Not applicable
* Notiication is required if inpatient stay exceeds 48 hours following a † Diagnosis and treatment of the underlying medical condition only. ART
normal vaginal delivery or 96 hours following a cesarean section delivery. coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer
** Prior authorization is required. (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo
*** Members can access CVS MinuteClinic for no cost, after deductible transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery.
Additional coverage for embryo and sperm cryopreservation and storage
is met. of cryopreserved embryos and sperm for all members. Coverage limited
**** Coverage levels differ for virtual visit coverage for behavioral health and to six courses of treatment, per member lifetime.
dermatology through Teladoc.
***** Eligible health services include gender reassignment counseling by Certain preventive medications will be provided at no cost (deductible and
copay waived).
a behavioral health provider, hormone therapy, surgical procedures,
physician pre-operative and post-operative hospital and ofice visits,
inpatient and outpatient services, skilled nursing facility care, outpatient Note: This medical plan summary provides only highlights of these beneits.
diagnostic testing, lab work and radiological services and blood Please refer to the oficial plan documents or Summary Plan Description,
transfusions. or contact your Human Resources Representative for speciic terms and
conditions, including limitations and exclusions.
10
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 $3,000 Individual $6,000 Individual
(Medical and Pharmacy; Includes copay, deductible, and coinsurance) $6,000 Family $12,000 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
> General Medicine Virtual Visits**** 100% after deductible 60% after deductible
> Specialist 80% after deductible
Preventive Care (well-baby, well-child, and well-adult; including 100%, 60% after deductible
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
Gender Reassignment***** 90% 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 Deductible then 60% of
Retail (30-day supply) submitted cost; after applicable
> Tier 1/Tier 2/Tier 3 Deductible then $10/$30/$60
Mail Order (90-day supply) copay
> Tier 1/Tier 2/Tier 3 Deductible then $25/$75/$125 Not applicable
* Notiication is required if inpatient stay exceeds 48 hours following a † Diagnosis and treatment of the underlying medical condition only. ART
normal vaginal delivery or 96 hours following a cesarean section delivery. coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer
** Prior authorization is required. (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo
*** Members can access CVS MinuteClinic for no cost, after deductible transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery.
Additional coverage for embryo and sperm cryopreservation and storage
is met. of cryopreserved embryos and sperm for all members. Coverage limited
**** Coverage levels differ for virtual visit coverage for behavioral health and to six courses of treatment, per member lifetime.
dermatology through Teladoc.
***** Eligible health services include gender reassignment counseling by Certain preventive medications will be provided at no cost (deductible and
copay waived).
a behavioral health provider, hormone therapy, surgical procedures,
physician pre-operative and post-operative hospital and ofice visits,
inpatient and outpatient services, skilled nursing facility care, outpatient Note: This medical plan summary provides only highlights of these beneits.
diagnostic testing, lab work and radiological services and blood Please refer to the oficial plan documents or Summary Plan Description,
transfusions. or contact your Human Resources Representative for speciic terms and
conditions, including limitations and exclusions.
10
