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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 $500 Individual $2,500 Individual
before the plan starts paying beneits; excludes copays) $1,000 Family $5,000 Family
Calendar Year Out-of-Pocket Maximum (includes $2,500 Individual $5,000 Individual
copay, deductible and coinsurance) $5,000 Family $10,000 Family
Lifetime Maximum Unlimited
Doctors’ Ofice Visits
Primary Care Physician (PCP)/Specialist visit $25 copay/$50 copay 70% after deductible
Preventive Care (well-baby, well-child, adult and well- 100%, 70% after deductible
woman; including immunizations) deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year $25 copay 60% after deductible
per member)
Maternity
> Visit to conirm pregnancy/Specialist visit $25 copay/$50 copay 60% after deductible
> 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% coinsurance 60% after deductible
Imaging (CT/PET scans, MRIs) 90% after deductible
Emergency Care
> Emergency Health Services/Urgent Care Facility $200 copay/$75 copay $200 copay†/70% 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— $25 copay 70% after deductible**
Outpatient
Mental Health and Substance Abuse Services— 90% after deductible 60% after deductible**
Inpatient and Intermediate
Acupuncture (100 visits per year per member) $25 copay 60% after deductible
Prescription Drugs
Retail (30-day supply)
> Tier 1/Tier 2/Tier 3 $10/$30/$60 20% of submitted cost; after
applicable copay
Mail Order (90-day supply)
> 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.
† 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. 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 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 $500 Individual $2,500 Individual
before the plan starts paying beneits; excludes copays) $1,000 Family $5,000 Family
Calendar Year Out-of-Pocket Maximum (includes $2,500 Individual $5,000 Individual
copay, deductible and coinsurance) $5,000 Family $10,000 Family
Lifetime Maximum Unlimited
Doctors’ Ofice Visits
Primary Care Physician (PCP)/Specialist visit $25 copay/$50 copay 70% after deductible
Preventive Care (well-baby, well-child, adult and well- 100%, 70% after deductible
woman; including immunizations) deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year $25 copay 60% after deductible
per member)
Maternity
> Visit to conirm pregnancy/Specialist visit $25 copay/$50 copay 60% after deductible
> 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% coinsurance 60% after deductible
Imaging (CT/PET scans, MRIs) 90% after deductible
Emergency Care
> Emergency Health Services/Urgent Care Facility $200 copay/$75 copay $200 copay†/70% 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— $25 copay 70% after deductible**
Outpatient
Mental Health and Substance Abuse Services— 90% after deductible 60% after deductible**
Inpatient and Intermediate
Acupuncture (100 visits per year per member) $25 copay 60% after deductible
Prescription Drugs
Retail (30-day supply)
> Tier 1/Tier 2/Tier 3 $10/$30/$60 20% of submitted cost; after
applicable copay
Mail Order (90-day supply)
> 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.
† 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. 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 HR Support for speciic terms and conditions, including limitations and exclusions.
5
