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Summary of Medical Beneits (continued)
Aetna EPO 1500*
* NO OUT-OF-NETWORK COVERAGE except for emergency situations.
Plan Features In-Network
Calendar Year Deductible (the amount you must pay before the $1,500 Individual
plan starts paying beneits; excludes copays) $3,000 Family
Calendar Year Out-of-Pocket Maximum $3,000 Individual
(includes copay, deductible and coinsurance) $6,000 Family
Lifetime Maximum Unlimited
Doctors’ Ofice Visits $30 copay/$60 copay
Primary Care Physician (PCP)/Specialist visit
Preventive Care (well-baby, well-child, adult and well-woman; 100%,
including immunizations) deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year per $30 copay
member)
Maternity
> Visit to conirm pregnancy/Specialist visit $30 copay/$60 copay
> Prenatal, Delivery and Postnatal* 80% after deductible
Hospital—Inpatient Stay 80% after deductible
Outpatient Surgery, Diagnostic and Therapeutic Services 80% after deductible
Diagnostic test (x-ray, blood work) 80% coinsurance
Imaging (CT/PET scans, MRIs) 80% after deductible
Emergency Care (out of network also covered)
> Emergency Health Services/Urgent Care Facility $200 copay/$75 copay
> Ambulance Services—Emergency only 80% after deductible
Infertility Services †† 80% after deductible
Mental Health and Substance Abuse Services—Outpatient $30 copay
Mental Health and Substance Abuse Services—Inpatient and 80% after deductible
Intermediate
Acupuncture (100 visits per year per member) $30 copay
Prescription Drugs
Retail (30-day supply)
> Tier 1/Tier 2/Tier 3 $10/$30/$60
Mail Order (90-day supply)
> Tier 1/Tier 2/Tier 3 $25/$75/$150
* Notiication is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
†† 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. 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 who are eligible for IVF.
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.
7
Aetna EPO 1500*
* NO OUT-OF-NETWORK COVERAGE except for emergency situations.
Plan Features In-Network
Calendar Year Deductible (the amount you must pay before the $1,500 Individual
plan starts paying beneits; excludes copays) $3,000 Family
Calendar Year Out-of-Pocket Maximum $3,000 Individual
(includes copay, deductible and coinsurance) $6,000 Family
Lifetime Maximum Unlimited
Doctors’ Ofice Visits $30 copay/$60 copay
Primary Care Physician (PCP)/Specialist visit
Preventive Care (well-baby, well-child, adult and well-woman; 100%,
including immunizations) deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year per $30 copay
member)
Maternity
> Visit to conirm pregnancy/Specialist visit $30 copay/$60 copay
> Prenatal, Delivery and Postnatal* 80% after deductible
Hospital—Inpatient Stay 80% after deductible
Outpatient Surgery, Diagnostic and Therapeutic Services 80% after deductible
Diagnostic test (x-ray, blood work) 80% coinsurance
Imaging (CT/PET scans, MRIs) 80% after deductible
Emergency Care (out of network also covered)
> Emergency Health Services/Urgent Care Facility $200 copay/$75 copay
> Ambulance Services—Emergency only 80% after deductible
Infertility Services †† 80% after deductible
Mental Health and Substance Abuse Services—Outpatient $30 copay
Mental Health and Substance Abuse Services—Inpatient and 80% after deductible
Intermediate
Acupuncture (100 visits per year per member) $30 copay
Prescription Drugs
Retail (30-day supply)
> Tier 1/Tier 2/Tier 3 $10/$30/$60
Mail Order (90-day supply)
> Tier 1/Tier 2/Tier 3 $25/$75/$150
* Notiication is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
†† 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. 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 who are eligible for IVF.
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.
7
