IL Aetna Silver $10 Copay Savings Plus OAMC PD


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IL Aetna Silver $10 Copay Savings Plus OAMC PD

Important Questions            Answers                                                            Why this Matters:

What is the overall deductible?

In-network: Individual $3,500 / Family
$7,000. Out-of-network: Individual $7,500 / Family $15,000. Does not apply to certain office visits, preventive care, urgent care and prescription drugs in-network.

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.

 

Yes. For prescription drug expenses per

 

Are there other deductibles for specific services?

member – In-network: $500 / Out-of-network: $1,000. Does not apply to in-network for preferred generic drugs. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Is there an out-of-pocket limit on my expenses?

Yes. In-network: Individual $6,250 / Family $12,500. Out-of-network: Individual Unlimited / Family Unlimited.

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.

 

Premiums, balance-billed charges, penalties

 

What is not included in the out-of-pocket limit?

for failure to obtain pre-authorization for services, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-of pocket limit.

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.

 

 

If you use an in-network doctor or other health care provider, this plan will pay

Does this plan use a network of providers?

Yes. See www.aetna.comor call 1-866-253-8885 for a list of in-network providers.

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.

Are there services this plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.

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

$10 copay/visit, deductible waived

50% coinsurance

–––––––––––none–––––––––––

Specialist visit

$75 copay/visit, deductible waived

50% coinsurance

–––––––––––none–––––––––––

Other practitioner office visit

30% coinsurance for
Chiropractic care

50% coinsurance for
Chiropractic care

Coverage is limited to 12 visits for Chiropractic care.

Preventive care /screening /immunization

No charge

50% coinsurance

Age and frequency schedules may apply.

If you have a test

Diagnostic test (x-ray, blood work)

30% coinsurance

50% coinsurance

–––––––––––none–––––––––––

Imaging (CT/PET scans, MRIs)

30% coinsurance after
$250 copay/visit

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

If you need drugs to treat your illness or condition.
 
More information about prescription
drug coverage is available at
www.aetna.com/phar macy-insurance/individ uals-families

Preferred generic drugs

Tier 1A: $5 copay (retail), $12.50 copay (mail order); Tier 1:
$15 copay (retail), $37.50 copay (mail
order), deductible waived

50% coinsurance,
(retail)

Covers up to a 30 day supply (retail prescription), 31-90 day supply (mail order prescription). Applicable cost share plus difference (brand minus generic cost) applies for brand when generic available. No charge for preferred generic
FDA-approved women’s contraceptives in-network. Precertification and step

Preferred brand drugs

$40 copay (retail), $100 copay (mail order)

50% coinsurance,
(retail)

Non-preferred generic/brand drugs

$75 copay (retail), $187.50 copay (mail order)

50% coinsurance,
(retail)

therapy required. No coverage for mail order prescriptions out-of-network.

Specialty drugs

Preferred: 40%
coinsurance for up to a 30 day supply;
Non-preferred: 50% coinsurance for up to a
30 day supply

Not covered

Aetna Specialty CareRxSM – First
Prescription must be filled at a participating retail pharmacy or Aetna Specialty Pharmacy®. Subsequent fills must be through Aetna Specialty Pharmacy®.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

30% coinsurance after
$250 copay/visit

50% coinsurance

–––––––––––none–––––––––––

Physician/surgeon fees

30% coinsurance

50% coinsurance

–––––––––––none–––––––––––

 

Emergency room services

$500 copay/visit

$500 copay/visit

Copay waived if admitted. Out-of-network emergency room services cost-share same as

If you need immediate medical attention

 

 

 

in-network.

Emergency medical transportation

30% coinsurance

30% coinsurance

Out-of-network cost-share same as in-network.

Urgent care

$75 copay/visit, deductible waived

50% coinsurance

–––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room)

30% coinsurance after
$500 copay/admission

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

Physician/surgeon fee

30% coinsurance

50% coinsurance

–––––––––––none–––––––––––

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

$75 copay/visit, deductible waived

50% coinsurance

–––––––––––none–––––––––––

Mental/Behavioral health inpatient services

30% coinsurance after
$500 copay/admission

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

Substance use disorder outpatient services

$75 copay/visit, deductible waived

50% coinsurance

–––––––––––none–––––––––––

Substance use disorder inpatient services

30% coinsurance after
$500 copay/admission

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

If you are pregnant

Prenatal and postnatal care

Prenatal: No charge; Postnatal: $250 one time copay, deductible waived

50% coinsurance

–––––––––––none–––––––––––

Delivery and all inpatient services

30% coinsurance after
$500 copay/admission

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

If you need help recovering or have
other special health needs

Home health care

30% coinsurance

50% coinsurance

–––––––––––none–––––––––––

Rehabilitation services

30% coinsurance

50% coinsurance

–––––––––––none–––––––––––

Habilitation services

30% coinsurance

50% coinsurance

–––––––––––none–––––––––––

Skilled nursing care

30% coinsurance

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

Durable medical equipment

50% coinsurance

50% coinsurance

–––––––––––none–––––––––––

Hospice service

30% coinsurance

50% coinsurance

Out-of-network precertification required or a 50% up to $1000 per occurrence penalty applies.

If your child needs dental or eye care

Eye exam

No charge

50% coinsurance

Coverage is limited to 1 exam per calendar year.

 

Glasses

No charge

50% coinsurance

Coverage is limited to 1 set of frames and 1 set of contact lenses or eyeglass lenses per calendar year.

Dental check-up

No charge

30% coinsurance

Coverage is limited to 2 exams per calendar year.

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
  • Acupuncture – except as form of anesthesia.
  • Cosmetic Surgery – except when medically necessary.
  • Dental care (Adult) – except accidental injury.
  • Long Term Care
  • Non-emergency care when traveling outide the U.S.
  • Routine eye care (Adult)
  • Routine foot care – except for diabetes.
  • Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)
  • Bariatric Surgery
  • Chiropractic Care – Coverage is limited to 12 visits.
  • Hearing aids – Covered expenses for prescribed hearing aids include hearing aids for children up to age 19, 1 per ear every 36 months; 1 bone anchored
    hearing aid and cochlear implant per ear every 36 months
  • Infertility Treatment – Benefit limitations may apply.
  • Private-duty nursing