Are there other
deductibles
for specific services?
No.
You don't have to meet
deductibles
for specific services, but see the chart starting on page
2 for other costs for services this plan covers.
Is there an
out-of-pocket limit
on my expenses?
Yes. In-network and out-of-network combined:
$2,900
individual/
$5,800
family.
The
out-of-pocket limit
is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health care
expenses.
What is not included in the
out-of-pocket limit
?
Premiums, penalties for failure to obtain pre-
authorization for services, balance-billed
charges and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the
out-of-pocket limit
.
Aetna HealthFund HRA80 Out-of-Network
Summary of Benefits and Coverage
: What this Plan Covers & What it Costs
Coverage Period
: 01/01/2014 - 12/31/2014
Coverage for
: Employee + Family |
Plan Type
: PPO/High Deductible
This is only a summary.
If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at
r by calling Aetna
One
Premier at 1-800-558-0860.
Important Questions
Answers
Why this Matters
What is the overall
deductible
?
In-network and out-of-network combined:
$1,300
individual/
$2,600
family.
Doesn't apply to preventive care and certain
preventive & chronic drugs. In-network and
out-of-network covered expenses will cross-
apply to satisfy both the in-network and out-of-
network deductibles.
You must pay all the costs up to the
deductible
amount before this plan begins to pay for
covered services you use. Check your policy or plan document to see when the
deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the
deductible
.
Are there services this
plan doesn't cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 6. See your policy or plan
document for additional information about
excluded services
.
Does Aetna contribute to a
Health Reimbursement
Arrangement ("HRA") on
my behalf?
Yes.
$400
individual /
$800
family
An HRA is an account that is set up and contributed to by Aetna. You may not make any
contributions to the HRA. The HRA may only be used to pay your out-of-pocket expenses
incurred under your Aetna medical plan, such as co-payments, deductibles and co-insurance
amounts. Any payments made from your HRA for eligible medical expenses are tax free.
Questions
: Call 1-800-558-0860 or visit
If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the
Glossary at
or call 1-800-AETNA-HR (1-800-238-6247) to request a copy.
Is there an overall annual
limit on what the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for
specific
covered services, such as office visits.
Does this plan use a
network
of
providers
?
Yes. For a list of in-network
providers
,
call 1-800-558-0860 or go to DocFind
at
If you use an in-network doctor or other health care
provider
, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network
provider
for some services. Plans use the term in-network,
preferred
, or
participating for
providers
in their
network
. See the chart starting on page 2 for how this
plan pays different kinds of
providers
.
Do I need a referral to
see a
specialist
?
No.
You can see the
specialist
you choose without permission from this plan.
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