Page 9 - GLG 2021 Annual Benefits
P. 9
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
> General Medicine Virtual Visits**** 100% after deductible
> Specialist Deductible then $50 copay
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) 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
Gender Reassignment***** 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 60% 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 † Prior authorization is required if results in an inpatient stay.
normal vaginal delivery or 96 hours following a cesarean section delivery. †† Diagnosis and treatment of the underlying medical condition only. ART
** Prior authorization is required. coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer
*** Members can access CVS MinuteClinic for no cost, after deductible (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo
transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery.
is met. Additional coverage for embryo and sperm cryopreservation and storage
**** Coverage levels differ for virtual visit coverage for behavioral health and of cryopreserved embryos and sperm for all members. Coverage limited
dermatology through Teladoc. to six courses of treatment, per member lifetime.
***** Eligible health services include gender reassignment counseling by Certain preventive medications will be provided at no cost (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.
9
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
> General Medicine Virtual Visits**** 100% after deductible
> Specialist Deductible then $50 copay
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) 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
Gender Reassignment***** 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 60% 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 † Prior authorization is required if results in an inpatient stay.
normal vaginal delivery or 96 hours following a cesarean section delivery. †† Diagnosis and treatment of the underlying medical condition only. ART
** Prior authorization is required. coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer
*** Members can access CVS MinuteClinic for no cost, after deductible (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo
transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery.
is met. Additional coverage for embryo and sperm cryopreservation and storage
**** Coverage levels differ for virtual visit coverage for behavioral health and of cryopreserved embryos and sperm for all members. Coverage limited
dermatology through Teladoc. to six courses of treatment, per member lifetime.
***** Eligible health services include gender reassignment counseling by Certain preventive medications will be provided at no cost (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.
9
