•
Copayments
are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
•
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
.
• 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.
If you have a test
Diagnostic test
(x-ray, blood work)
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Imaging
(CT/PET scans, MRIs)
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Common Medical Event Services You May Need
Your cost if you use an In-
Network Provider
Your cost if you use an
Out-of-Network
Provider
Limitations & Exceptions
If you visit a health care
provider’s office or clinic
Primary care visit to treat an
injury or illness
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Specialist visit
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Other practitioner office visit
20%
coinsurance
20%
coinsurance
Chiropractic care (limited to 26 visits per
calendar year). Acupuncture only covered
in lieu of anesthesia.
Preventive care/
screening/
immunization
No charge
No charge
Age and frequency schedules may apply.
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is
available on Aetna Navigator at
r call Aetna
One
Premier
at 1-800-558-0860.
Generic drugs
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
Retail
: 35% copay
($75 maximum)
Mail order
: 35% copay
($150 maximum)
Not covered
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