Specialist visit
20%
coinsurance
Other practitioner
office visit
APN/Aexcel network not
applicable
If you visit a health care
provider’s office or clinic
50%
coinsurance
Common Medical Event
Services You May
Need
Your cost if you use
an APN and/or
Aexcel Network
Provider
Primary care visit to
treat an injury or illness
APN/Aexcel network not
applicable
Age and frequency schedules may apply.
50%
coinsurance
•
Coinsurance
is
your
share of the costs of a covered service, calculated as a percent of the
allowed amount
for the service. For example, if the plan’s
allowed
amount
for an overnight hospital stay is $1,000, your
coinsurance
payment of 20% would be $200. This may change if you haven’t met your
deductible
.
Your cost if
you use an
Out-of-
Network
Provider
50%
coinsurance
Preventive care/
screening/
immunization
APN/Aexcel network not
applicable
Your cost if you use an
In-Network Provider
20%
coinsurance
20% coinsurance if you are
not in an Aexcel or APN
network;
40% coinsurance if you are in
an Aexcel/APN network
20%
coinsurance
No charge
Chiropractic care (limited to 26 visits per
calendar year). Acupuncture only covered
in lieu of anesthesia.
• The amount the plan pays for covered services is based on the
allowed amount
. If an out-of-network
provider
charges more than the
allowed amount
, you may have
to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the
allowed amount
is $1,000, you may have to pay the $500
difference. (This is called
balance billing
.)
•
This plan may encourage you to use in-network
providers
(including the Aetna Performance Network ("APN") for hospitals and specialists and the Aexcel network for
specialists, if applicable in your zip code, by charging you lower
deductibles
,
copayments
and
coinsurance
amounts
.
There is no coverage when you receive care from
out-of-network providers, except for emergency care.
•
Copayments
are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Limitations & Exceptions
50%
coinsurance
––––––––––– None –––––––––––
The APN network includes the following
20 physician specialties: Cardiology*,
Gastroenterology*, General Surgery*,
Orthopedics*, Neurology*,
Neurosurgery*, Obstetrics/Gynecology*,
Cardiothoracic Surgery*, Vascular
Surgery*, Otolaryngology (ENT)*,
Plastic Surgery*, Urology*, Allergy/
Immunology, Dermatology,
Endocrinology, Infectious Disease,
Nephrology, Ophthalmology, Pulmonary
Critical Care and Rheumatology. The
Aexcel network includes the 12
specialties in the preceding sentence that
are marked with an asterisk (*).
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