Details at a Glance

• Plan Type
• PPO
• Office Visit for Primary Doctor
• $30 Copay
• Office Visit for Specialist
• $40 Copay
• Coinsurance
• 20% after deductible
• Separate Prescription Drugs Deductible
• $500 Individual
  applies to
  Brand, Non-Formulary
• Prescription Drugs
• Generic: $15 Copay
• Brand: $25 Copay
• Non-Formulary: $40 Copay
• Health Savings Account (HSA) Eligible
• No
• Out-of-Network Coverage
• Yes  (Details in plan brochure below)
• Out of Country Coverage
• Yes. Paid as out-of-network benefits 

Physicians

• Primary Care Physician (PCP) Required
• No
• Specialist Referrals Required
• No

Preventive Care Coverage

• Periodic Health Exam
• $30 Copay
• Periodic OB-GYN Exam
• No charge
• Well Baby Care
• $30 copay Age and frequency schedule apply

Prescription Drug Coverage

• Generic Prescription Drugs
• $15 Copay
• Brand Prescription Drugs
• $25 Copay
• Non-Formulary Prescription Drugs Coverage
• $40 Copay
• Mail Order for Prescription Drugs
• Generic: $30 Copay
• Brand: $50 Copay
• Non-Formulary: $80 Copay
• Days Supply: 60
• Separate Prescription Drugs Deductible
• $500 Individual
  applies to
  Brand, Non-Formulary

Hospital Services Coverage

• Emergency Room
• $100 Copay (waived if admitted) plus 20% Coinsurance after deductible
• Outpatient Lab/X-Ray
• 20% Coinsurance after deductible
• Outpatient Surgery
• 20% Coinsurance after deductible
• Hospitalization
• 20% Coinsurance after deductible

Maternity Coverage

• Pre & Postnatal Office Visit
• Not covered (except for pregnancy complications)
• Labor & Delivery Hospital Stay
• Not covered (except for pregnancy complications)

Additional Coverage

• Chiropractic Coverage
• 20% Coinsurance after deductible. Aetna will pay $25 Max. Per Visit/ 24Visits Per Year.
• Mental Health Coverage
• Not covered except for severe, biologically based mental or nervous disorders and associated treatment of drug and alcohol dependencies.

Additional Information

• A.M. Best Rating
• A as of 06/17/2009
• Electronic Signature for Application Available
• Yes
• Will insurance company obtain and pay for medical records?
• Yes
• Additional information about this health insurance plan is available in the documents below.
  Plan Brochure
  Exclusions and Limitations

Action

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