Common Medical Event
Services You May
Need
Your cost if you use
an APN and/or
Aexcel Network
Provider
If you have a test
Diagnostic test (x-ray,
blood work)
Imaging
(CT/PET scans, MRIs)
Preferred brand drugs
Non-preferred brand
drugs
Specialty / self-
injectable drugs
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is
available on Aetna Navigator at
or call Aetna
One
Premier
at 1-800-558-0860.
Generic drugs
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
Limitations & Exceptions
20% coinsurance if you are
not in an Aexcel or APN
network;
40% co-insurance if you are
in an Aexcel/APN network
20%
coinsurance
Facility fee (e.g.,
ambulatory surgery
center)
Not covered
––––––––––– None –––––––––––
First prescription may be filled at any
retail or mail order drug facility.
Subsequent fills must be through Aetna
Specialty Pharmacy®.
50%
coinsurance
50%
coinsurance
––––––––––– None –––––––––––
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.
Your cost if
you use an
Out-of-
Network
Provider
50%
coinsurance
Not covered
Not covered
Not covered
Preferred
drugs: 10% co-pay
($125 maximum)
Non-preferred
drugs:
30% co-pay
($250 maximum)
If you have outpatient surgery
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.
Your cost if you use an
In-Network Provider
20% coinsurance for
independent labs and
outpatient x-ray; 40%
coinsurance for hospital
(outpatient) labs
20%
coinsurance
Retail
: $10 copay
Mail order
: $25 copay
Retail
: 35% copay
($75 maximum)
Mail order
: 35% copay
($150 maximum)
Retail
: 50% copay
($125 maximum)
Mail order
: 50% copay
($250 maximum)
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