Page 36 - Aetna - Summary of Benefits and Coverage

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®.
No out-of-network coverage.
If you have outpatient surgery
Facility fee (e.g.,
ambulatory surgery
center)
20%
coinsurance
40%
coinsurance
Not covered
Transplant services received at any
facility that is not an Institutes of
Excellence facility are not covered
Transplant services are not covered
within the Memorial Hermann ACN.
Precertification rules must be followed or
benefits are reduced by 50%, up to a
$1,000 maximum. No out-of-network
coverage.
Physician/surgeon fees
20%
coinsurance
40%
coinsurance
Not covered
Common Medical Event
Services You May
Need
Your cost if you use
a Memorial Hermann
ACN Provider
Your cost if you use an
In-Network Provider
Your cost if
you use an
Out-of-
Network
Provider
Limitations & Exceptions
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
Memorial Hermann ACN
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
Memorial Hermann ACN
not applicable
Retail : 35% copay
($75 maximum)
Mail order : 35% copay
($150 maximum)
Not covered
Non-preferred brand
drugs
Memorial Hermann ACN
not applicable
Retail : 50% copay
($125 maximum)
Mail order : 50% copay
($250 maximum)
Not covered
Specialty / self-
injectable drugs
Memorial Hermann ACN
not applicable
Page 35 of 48