Page 12 - Aetna - Summary of Benefits and Coverage

If you have a test
Diagnostic test (x-ray,
blood work)
APN/Aexcel network not
applicable
20% coinsurance for
independent labs and
outpatient x-ray; 40%
coinsurance for hospital
(outpatient) labs
50%
coinsurance
––––––––––– None –––––––––––
Imaging
(CT/PET scans, MRIs)
APN/Aexcel network not
applicable
20%
coinsurance
50%
coinsurance
––––––––––– None –––––––––––
Common Medical Event
Services You May
Need
Your cost if you use
an APN and/or
Aexcel Network
Provider
Your cost if you use an
In-Network Provider
Your cost if
you use an
Out-of-
Network
Provider
Limitations & Exceptions
If you have outpatient surgery
Facility fee (e.g.,
ambulatory surgery
center)
20%
coinsurance
20% coinsurance if you are
not in an Aexcel or APN
network;
40% co-insurance if you are
in an Aexcel/APN network
50%
coinsurance
Bariatric/transplant services received at
any facility that is not an Institutes of
Quality or Excellence facility are not
covered; APN/Aexcel does not apply.
Precertification rules must be followed or
benefits are reduced by 50%, up to a
$1,000 max. APN is not applicable to
free-standing ambulatory surgery centers.
If you need drugs to treat
your illness or condition
More information about
prescription drug coverageis
available on Aetna Navigator at
www.aetna.com or call Aetna
One Premier
at 1-800-558-0860.
Generic drugs
APN/Aexcel network not
applicable
Retail : $10 copay
Mail order : $25 copay
Not covered
Covers up to a 30-day supply at retail; 31-
90 day supply for mail order; 90-day
supply of maintenance medications at
CVS/pharmacy. Certain contraceptive
drugs and devices are available with no
cost share.
No out-of-network coverage.
Preferred brand drugs
APN/Aexcel network not
applicable
Retail : 35% copay
($75 maximum)
Mail order : 35% copay
($150 maximum)
Not covered
Non-preferred brand
drugs
APN/Aexcel network not
applicable
Retail : 50% copay
($125 maximum)
Mail order : 50% copay
($250 maximum)
Not covered
Specialty / self-
injectable drugs
APN/Aexcel network not
applicable
Preferred drugs: 10% co-pay
($125 maximum)
Non-preferred drugs:
30% co-pay
($250 maximum)
Not covered
First prescription may be filled at any
retail or mail order drug facility.
Subsequent fills must be through Aetna
Specialty Pharmacy®
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