10% with minimum & after specific : First prescription fill at a retail pharmacy or $25 minimum & specialty pharmacy. Subsequent fills must be Not covered $100 maximum through the Aetna Specialty Pharmacy . (preferred), $45 Precertification required for coverage. minimum & $100 maximum $30 /visit, doesn't Facility fee (e.g., ambulatory surgery center) 20% None If you have apply outpatient surgery Physician/surgeon fees No charge 20% None $100 /visit, doesn't $100 /visit, doesn't No coverage for non-emergency use. apply apply If you need immediate medical No charge No charge No coverage for non-emergency transport. attention $30 /visit, doesn't $30 /visit, doesn't No coverage for non-urgent use. apply apply Penalty of $400 per occurrence for failure to Facility fee (e.g., hospital room) $100 /stay 20% If you have a obtain for out-of-network care. hospital stay Physician/surgeon fees 0% 20% None Office: $15 /visit, Office & other If you need mental doesn't apply; other Outpatient services outpatient services: None health, behavioral outpatient services: 20% health, or no charge substance abuse Penalty of $400 per occurrence for failure to services Inpatient services $100 /stay 20% obtain for out-of-network care. Office visits No charge 20% does not apply for . Maternity care may include tests and services described elsewhere in the Childbirth/delivery professional services 0% 20% If you are pregnant SBC (i.e. ultrasound.) Penalty of $400 per occurrence for failure to obtain for out-of-network Childbirth/delivery facility services $100 /stay 20% care may apply.
10% with minimum & after specific : $25 minimum & $100 maximum (preferred), $45 minimum & $100 maximum Not covered First prescription fill at a retail pharmacy or specialty pharmacy. Subsequent fills must be through the Aetna Specialty Pharmacy . Precertification required for coverage. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $30 /visit, doesn't apply 20% None Physician/surgeon fees No charge 20% None If you need immediate medical attention $100 /visit, doesn't apply $100 /visit, doesn't apply No coverage for non-emergency use. No charge No charge No coverage for non-emergency transport. $30 /visit, doesn't apply $30 /visit, doesn't apply No coverage for non-urgent use. If you have a hospital stay Facility fee (e.g., hospital room) $100 /stay 20% Penalty of $400 per occurrence for failure to obtain for out-of-network care. Physician/surgeon fees 0% 20% None If you need mental health, behavioral health, or substance abuse services Outpatient services Office: $15 /visit, doesn't apply; other outpatient services: no charge Office & other outpatient services: 20% None Inpatient services $100 /stay 20% Penalty of $400 per occurrence for failure to obtain for out-of-network care. If you are pregnant Office visits No charge 20% does not apply for . Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Penalty of $400 per occurrence for failure to obtain for out-of-network care may apply. Childbirth/delivery professional services 0% 20% Childbirth/delivery facility services $100 /stay 20%
summary%20of%20benefits%20and%20coverages.docx