20%
coinsurance
––––––––––– None –––––––––––
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.
Non-preferred brand drugs
Retail
: 50% copay
($125 maximum)
Mail order
: 50% copay
($250 maximum)
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.
Specialty / self-injectable drugs
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®
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 have outpatient surgery
Facility fee (e.g., ambulatory
surgery center)
20%
coinsurance
20%
coinsurance
Bariatric/transplant services received at
any facility that is not an Institutes of
Quality or Excellence facility are not
covered. Precertification rules must be
followed or benefits are reduced by 50%,
up to a $1,000 maximum.
Physician/surgeon fees
20%
coinsurance
20%
coinsurance
If you need immediate
medical attention
Emergency room services
20%
coinsurance
20%
coinsurance
Non emergency use not covered.
Emergency medical
transportation
20%
coinsurance
20%
coinsurance
Non emergency use not covered.
Urgent care
20%
coinsurance
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