2021 Open Enrollment Please read your attachments regarding your Summary of Benefits Coverage - Lee County
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2021 Open Enrollment
Please read your attachments
regarding your Summary of Benefits
Coverage.
Lee County Board of County Commissioners Comparison Chart
This comparison was prepared to highlight general differences between plan benefits, it is not to be construed as a complete description of benefits.
Aetna Choice POS II Aetna OA Select
Aetna Group Retiree
Secondary to Medicare Secondary to Medicare
Medicare Advantage ESAPPO Plan
(current benefits) (current benefits)
In-Network and Out-of-Network In-Network and Out-of-Network In-Network (No Out of Network Coverage)
Annual Medical Deductible None $500/$1000 Out of Network None
Annual Medical Out-of-Pocket Maximum $1,500 $1,500 $1,500
Office Visits - PCP $10 copay $10 copay $10 copay
Office Visits - Specialist $35 copay $35 copay $25 copay
Inpatient Hospital Coverage $500 copay per admit $500 copay per admit $500 copay per admit
Diagnostic Laboratory and X-ray except
$35 copay $35 copay $25 copay
for Complex Imaging
Diagnostic X-ray for Complex Imaging $50 copay $50 copay $50 copay
Urgent Care Provider $50 copay $50 copay $50 copay
Emergency Room $65 copay $150 copay $150 copay
Ambulance $0 copay $0 copay $0 copay
Durable Medical Equipment $0 copay $0 copay $0 copay
Routine Podiatry $35 copay $35 copay $25 copay
Outpatient Surgery $200 copay $200 copay $200 copay
Outpatient Mental Health $35 copay $35 copay $25 copay
Outpatient Alcohol / Drug Abuse $35 copay $10 copay $10 copay
PREVENTIVE CARE
Routine Adult Physical Exams $0 copay $0 copay $0 copay
Immunizations $0 copay $0 copay $0 copay
Routine Gynecological Care Exams $0 copay $0 copay $0 copay
Routine Mammograms $0 copay $0 copay $0 copay
Colorectal Cancer Screening $0 copay $0 copay $0 copay
Routine Eye Exams $0 copay $0 copay $0 copay
Routine Hearing Exams $0 copay $0 copay $0 copay
Hearing Aid Reimbursement $500 every 36 months Yes, up to $2,500 Yes, up to $2,500
Meals after Inpatient Care Included Not Included Not Included
Prescription Drugs
$10 copay Generics $10 copay Generics $10 copay Generics
$20 copay Preferred Brand-name $20 copay Preferred Brand-name $20 copay Preferred Brand-name
$35 copay Non-Preferred Brand-name $35 copay Non-Preferred Brand-name $35 copay Non-Preferred Brand-name
Pharmacy Retail $35 copay Specialty drugs $35 copay Specialty drugs $35 copay Specialty drugs
(Up to a 30 day supply at a Network (Up to a 30 day supply at a Network (Up to a 30 day supply at a Network
Pharmacy) Pharmacy) Pharmacy)
$0 copay Generics $0 copay Generics $0 copay Generics
$40 copay Preferred Brand-name $40 copay Preferred Brand-name $40 copay Preferred Brand-name
$70 copay Non-Preferred Brand-name $70 copay Non-Preferred Brand-name $70 copay Non-Preferred Brand-name
Pharmacy Mail Order $70 copay Specialty drugs $70 copay Specialty drugs $70 copay Specialty drugs
(Up to a 90 day supply for Retail and (Up to a 90 day supply for Retail and (Up to a 90 day supply for Retail and
Mail Order Service) Mail Order Service) Mail Order Service)
Formulary Covers all Medicare approved drugs Covers all Medicare approved drugs Covers all Medicare approved drugs
Step Therapy Not Included Not Included Not Included
Coverage Gap (Donut Hole) Same copays as above Same copays as above Same copays as above
Wellness Benefits
Fitness / SilverSneakers Silver Sneakers Global Fitness Global Fitness
Caregiver Included Included Included
NurseLine Included Included Included
Disease Management
Chronic Heart Failure (CHF)
Included Included Included
Coronary Artery Disease (CAD)/Diabetes
End Stage Renal Disease (ESRD)
Group Retiree Case Management Included Included Included
Advanced Illness Care Management Included Included IncludedLEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Benefits and Premiums are effective January 1, 2021 through December 31, 2021
SUMMARY OF BENEFITS
PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES Network & out-of-network providers
Annual Deductible $0
This is the amount you have to pay out of pocket before the plan will pay its share for your
covered Medicare Part A and B services.
Monthly Premium Please contact your former employer/union/trust for
more information on your plan premium.
Annual Maximum Out-of-Pocket $1,500
Amount
Annual maximum out-of-pocket limit amount includes any deductible, copayment or
coinsurance that you pay. It will apply to all medical expenses except hearing aid
reimbursement, vision reimbursement and Medicare prescription drug coverage that may
be available on your plan.
HOSPITAL CARE This is what you pay for Network & out-of-network
providers
Inpatient Hospital Care $500 per stay
The member cost sharing applies to covered benefits incurred during a member's inpatient
stay.
Prior authorization or physician's order may be required.
Outpatient Hospital Care $200
Prior authorization or physician's order may be required.
PHYSICIAN SERVICES This is what you pay for network & out-of-network
providers
Primary Care Physician Visits $10
Includes services of an internist, general physician, family practitioner for routine care as
well as diagnosis and treatment of an illness or injury and in-office surgery.
Physician Specialist Visits $35
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Primary Care Physician Selection Optional
There is no requirement for member pre-certification. Your provider will do this on your
behalf.
Referral Requirement None
PREVENTIVE CARE This is what you pay for network & out-of-network
providers
Annual Wellness Exams $0
One exam every 12 months.
Routine Physical Exams $0
One exam every 12 months.
Medicare Covered Immunizations $0
Pneumococcal, Flu, Hepatitis B
Routine GYN Care (Cervical and $0
Vaginal Cancer Screenings)
One routine GYN visit and pap smear every 24 months.
Routine Mammograms (Breast $0
Cancer Screening)
One baseline mammogram for members age 35-39; and one annual mammogram for
members age 40 & over.
Routine Prostate Cancer Screening $0
Exam
For covered males age 50 & over, every 12 months.
Routine Colorectal Cancer $0
Screening
For all members age 50 & over.
Routine Bone Mass Measurement $0
Medicare Diabetes Prevention $0
Program (MDPP)
12 months of core session for program eligible members with an indication of pre-diabetes.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Additional Medicare Preventive $0
Services
• Ultrasound screening for abdominal aortic aneurysm (AAA)
• Cardiovascular disease screening
• Diabetes screening tests and diabetes self-management training (DSMT)
• Medical nutrition therapy
• Glaucoma screening
• Screening and behavioral counseling to quit smoking and tobacco use
• Screening and behavioral counseling for alcohol misuse
• Adult depression screening
• Behavioral counseling for and screening to prevent sexually transmitted infections
• Behavioral therapy for obesity
• Behavioral therapy for cardiovascular disease
• Behavioral therapy for HIV screening
• Hepatitis C screening
• Lung cancer screening
EMERGENCY AND URGENT This is what you pay for network & out-of-network
MEDICAL CARE providers
Emergency Care; Worldwide $65
(waived if admitted)
Urgently Needed Care; Worldwide $50
DIAGNOSTIC PROCEDURES This is what you pay for network & out-of-network
providers
Outpatient Diagnostic Laboratory $35
Prior authorization or physician's order may be required.
Outpatient Diagnostic X-ray $35
Prior authorization or physician's order may be required.
Outpatient Diagnostic Testing $35
Prior authorization or physician's order may be required.
Outpatient Complex Imaging $50
Prior authorization or physician's order may be required.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
HEARING SERVICES This is what you pay for network & out-of-network
providers
Routine Hearing Screening $0
One exam every 12 months.
Hearing Aid Reimbursement $500 once every 36 months
Applies to in or out of network
DENTAL SERVICES This is what you pay for network & out-of-network
providers
Medicare Covered Dental $35
Non-routine care covered by Medicare.
Prior authorization or physician's order may be required.
VISION SERVICES This is what you pay for network & out-of-network
providers
Routine Eye Exams $0
One annual exam every 12 months.
Diabetic Eye Exams $0
MENTAL HEALTH SERVICES This is what you pay for network & out-of-network
providers
Inpatient Mental Health Care $500 per stay
The member cost sharing applies to covered benefits incurred during a member's inpatient
stay.
Prior authorization or physician's order may be required.
Outpatient Mental Health Care $35
Prior authorization or physician's order may be required.
Inpatient Substance Abuse $500 per stay
The member cost sharing applies to covered benefits incurred during a member's inpatient
stay.
Prior authorization or physician's order may be required.
Outpatient Substance Abuse $35
Prior authorization or physician's order may be required.
SKILLED NURSING SERVICES This is what you pay for Network & out-of-network
providers
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Skilled Nursing Facility (SNF) Care $0 copay per day, day(s) 1-100
Limited to 100 days per Medicare Benefit Period*.
The member cost sharing applies to covered benefits incurred during a member's inpatient
stay.
Prior authorization or physician's order may be required.
*A benefit period begins the day you go into a hospital or skilled nursing facility. The
benefit period ends when you haven’t received any inpatient hospital care (or skilled care
in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one
benefit period has ended, a new benefit period begins. There is no limit to the number of
benefit periods.
PHYSICAL THERAPY SERVICES This is what you pay for network & out-of-network
providers
Outpatient Rehabilitation Services $35
(Speech, Physical, and Occupational therapy)
Prior authorization or physician's order may be required.
AMBULANCE SERVICES This is what you pay for network & out-of-network
providers
Ambulance Services $0
Prior authorization or physician's order may be required.
MEDICARE PART B DRUGS This is what you pay for network & out-of-network
nroviders
Medicare Part B Prescription Drugs 20%
ADDITIONAL SERVICES This is what you pay for network & out-of-network
providers
Blood All components of blood are covered beginning with
Covered in and out of network the first pint.
Observation Care Your cost share for Observation Care is based upon
Covered in and out of network the services you receive.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Outpatient Surgery $200
Prior authorization or physician's order may be required.
Home Health Agency Care $0
Prior authorization or physician's order may be required.
Hospice Care Covered by Original Medicare at a Medicare certified
hospice.
Cardiac Rehabilitation Services $35
Pulmonary Rehabilitation Services $30
Radiation Therapy $35
Chiropractic Services $10
Limited to Original Medicare - covered services for manipulation of the spine.
Prior authorization or physician's order may be required.
Durable Medical Equipment/ $0
Prosthetic Devices
Prior authorization or physician's order may be required.
Podiatry Services $35
Limited to Original Medicare covered benefits only.
Diabetic Supplies $0
Includes supplies to monitor your blood glucose from LifeScan.Prior authorization or
physician's order may be required.
Outpatient Dialysis Treatments $30
Prior authorization or physician's order may be required.
ADDITIONAL NON-MEDICARE This is what you pay for network & out-of-network
COVERED SERVICES providers
Fitness Benefit Silver Sneakers
Meals Covered up to 14 meals following an inpatient stay.
Prior authorization or physician's order may be required.
Resources For Living® Covered
For help locating resources for every day needs.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Telehealth Covered
Telemedicine services
Routine Podiatry $35
PHARMACY - PRESCRIPTION DRUG BENEFITS
$0
Calendar-year deductible for prescription drugs
Prescription drug calendar year deductible must be satisfied before any Medicare
Prescription Drug benefits are paid. Covered Medicare Prescription Drug expenses will
accumulate toward the pharmacy deductible.
Pharmacy Network S2
Your Medicare Part D plan is associated with pharmacies in the above network. To find a
network pharmacy, you can visit our website (http://www.aetnaretireeplans.com).
Formulary (Drug List) Open 2 Plus
Initial Coverage Limit (ICL) $4,130
The Initial Coverage Limit includes the plan deductible, if applicable. This is your cost sharing until covered
Preferred
Retail cost Retail cost
mail order
sharing up sharing up
4 Tier Plan cost sharing
to a 30 -day to a 90 -day
up to a 90 -
supply supply
day supply
Tier 1 - Generic $10 $0 $0
Generic Drugs
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Tier 2 - Preferred $20 $40 $40
Brand
Preferred Brand Drugs
Tier 3 - Non-Preferred $35 $70 $70
Brand
Non-Preferred Brand
Drugs
Tier 4 - Specialty $35 Limited to Limited to
Includes high- one-month one-month
cost/unique generic supply supply
and brand drugs
Coverage Gap
The Coverage Gap starts once covered Medicare prescription drug expenses have reached
the Initial Coverage Limit. Here’s your cost-sharing for covered Part D drugs after the Initial
Coverage Limit and until you reach $6,550 in prescription drug expenses:
Your former employer/union/trust provides additional coverage during the Coverage Gap
stage for covered drugs. This means that you will generally continue to pay the same
amount for covered drugs throughout the Coverage Gap stage of the plan as you paid in
the Initial Coverage stage. Coinsurance-based cost-sharing is applied against the overall
cost of the drug, prior to the application of any discounts or benefits.
Catastrophic Coverage: You pay $3.70 for a generic drug or a drug that is treate
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Catastrophic Coverage benefits start once $6,550 in true out-of-pocket costs is incurred.
Requirements:
Precertification Applies
Step-Therapy Does Not Apply
Enhanced Drug Benefit
• Not Covered
For more information about Aetna plans, go to www.aetna.com or call Member Services at
toll-free at 1-888-267-2637 (TTY: 711). Hours are 8 a.m. to 6 p.m. local time, Monday
through Friday.
Medical Disclaimers
The provider network may change at any time. You will receive notice when necessary.
Participating physicians, hospitals and other health care providers are independent
contractors and are neither agents nor employees of Aetna. The availability of any
particular provider cannot be guaranteed, and provider network composition is subject to
change.
In case of emergency, you should call 911 or the local emergency hotline. Or you should go
directly to an emergency care facility.
The complete list of services can be found in the Evidence of Coverage (EOC). You can
request a copy of the EOC by contacting Member Services at 1-888-267-2637 (TTY: 711).
Hours are 8 a.m. to 9 p.m. EST, Monday through Friday.
The following is a partial list of what isn’t covered or limits to coverage under this plan:
• Services that are not medically necessary unless the service is covered by
Original Medicare or otherwise noted in your Evidence of Coverage
• Plastic or cosmetic surgery unless it is covered by Original Medicare
• Custodial care
• Experimental procedures or treatments that Original Medicare doesn’t cover
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
• Outpatient prescription drugs unless covered under Original Medicare Part B
You may pay more for out-of-network services. Prior approval from Aetna is required for
some network services. For services from a non-network provider, prior approval from
Aetna is recommended. Providers must be licensed and eligible to receive payment under
the federal Medicare program and willing to accept the plan.
Out-of-network/non-contracted providers are under no obligation to treat Aetna members,
except in emergency situations. Please call our Customer Service number or see your
Evidence of Coverage for more information, including the cost-sharing that applies to out-
of-network services.
Aetna will pay any non contracted provider (that is eligible for Medicare payment and is
willing to accept the Aetna Medicare Plan) the same as they would receive under Original
Medicare for Medicare covered services under the plan.
Pharmacy Disclaimers
Aetna’s retiree pharmacy coverage is an enhanced Part D Employer Group Waiver Plan that
is offered as a single integrated product. The enhanced Part D plan consists of two
components: basic Medicare Part D benefits and supplemental benefits. Basic Medicare
Part D benefits are offered by Aetna based on our contract with CMS. We receive monthly
payments from CMS to pay for basic Part D benefits. Supplemental benefits are non-
Medicare benefits that provide enhanced coverage beyond basic Part D. Supplemental
benefits are paid for by plan sponsors or members and may include benefits for non-Part D
drugs. Aetna reports claim information to CMS according to the source of applicable
payment (Medicare Part D, plan sponsor or member).
The formulary and/or pharmacy network may change at any time. You will receive notice
when necessary.
You must use network pharmacies to receive plan benefits except in limited, non-routine
circumstances as defined in the EOC. In these situations, you are limited to a 30 day supply.
Pharmacy clinical programs such as precertification, step therapy and quantity limits may
apply to your prescription drug coverage.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
If you reside in a long-term care facility, your cost share is the same as at a retail pharmacy
and you may receive up to a 31 day supply.
Specialty pharmacies fill high-cost specialty drugs that require special handling. Although
specialty pharmacies may deliver covered medicines through the mail, they are not
considered “mail-order pharmacies.” Therefore, most specialty drugs are not available at
the mail-order cost share.
For mail-order, you can get prescription drugs shipped to your home through the network
mail-order delivery program. Typically, mail-order drugs arrive within 7-10 days. You can
call 1-888-792-3862, (TTY users should call 711) 24 hours a day, seven days a week, if you
do not receive your mail-order drugs within this timeframe. Members may have the option
to sign-up for automated mail-order delivery.
The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand
name drugs. The amount you pay and the amount discounted by the manufacturer count
toward your out-of-pocket costs as if you had paid them and moves you through the
coverage gap.
Coinsurance-based cost-sharing is applied against the overall cost of the drug, prior to the
application of any discounts or benefits.
There are three general rules about drugs that Medicare drug plans will not cover under
Part D. This plan cannot:
• Cover a drug that would be covered under Medicare Part A or Part B.
• Cover a drug purchased outside the United States and its territories.
• Generally cover drugs prescribed for “off label” use, (any use of the drug other
than indicated on a drug's label as approved by the Food and Drug Administration)
unless supported by criteria included in certain reference books like the American
Hospital Formulary Service Drug Information, the DRUGDEX Information System and
the USPDI or its successor.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
Additionally, by law, the following categories of drugs are not normally covered by a
Medicare prescription drug plan unless we offer enhanced drug coverage for which
additional premium may be charged. These drugs are not considered Part D drugs and may
be referred to as “exclusions” or “non-Part D drugs”. These drugs include:
• Drugs used for the treatment of weight loss, weight gain or anorexia
• Drugs used for cosmetic purposes or to promote hair growth
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations
• Outpatient drugs that the manufacturer seeks to require that associated tests or
monitoring services be purchased exclusively from the manufacturer as a condition
of sale
• Drugs used to promote fertility
• Drugs used to relieve the symptoms of cough and colds
• Non-prescription drugs, also called over-the-counter (OTC) drugs
• Drugs when used for the treatment of sexual or erectile dysfunction
Plan Disclaimers
Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Enrollment in our plans
depends on contract renewal.
Participating physicians, hospitals and other health care providers are independent
contractors and are neither agents nor employees of Aetna. The availability of any
particular provider cannot be guaranteed, and provider network composition is subject to
change. Plans are offered by Aetna Health Inc., Aetna Health of California Inc., and/or Aetna
Life Insurance Company (Aetna).
You must be entitled to Medicare Part A and continue to pay your Part B premium and Part
A, if applicable.
See Evidence of Coverage for a complete description of plan benefits, exclusions,
limitations and conditions of coverage. Plan features and availability may vary by service
area.
If there is a difference between this document and the Evidence of Coverage (EOC), the
EOC is considered correct.
# Proprietary July 2020 24516_1_24517_1LEE COUNTY BOARD OF COUNTY COMMISSIONERS
Aetna Medicare ℠ Plan (PPO)
Medicare (V01) ESA PPO Plan
Rx $10/$20/$35/$35
You can read the Medicare & You 2021 Handbook. Every year in the fall, this booklet is
mailed to people with Medicare. It has a summary of Medicare benefits, rights and
protections, and answers to the most frequently asked questions about Medicare. If you
don’t have a copy of this booklet, you can get it at the Medicare website
(http://www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, 7 days a week. TTY users should call 1-877-486-2048.
ATTENTION: If you speak another language, language assistance services, free of charge,
are available to you. Call 1-888-267-2637 (TTY: 711). Spanish: ATENCIÓN: si habla español,
tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-267-2637
(TTY: 711). Traditional Chinese:
注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-888-267-2637 (TTY: 711).
You can also visit our website at www.aetnaretireeplans.com. As a reminder, our website
has the most up-to-date information about our provider network (Provider Directory) and
our list of covered drugs (Formulary/Drug List).
Information is believed to be accurate as of the production date; however, it is subject to
change. For more information about Aetna plans, go to www.aetna.com.
This document is not intended to be member-facing as it does not include the required
disclosures.
***This is the end of this plan benefit summary***
©2020 Aetna Inc.
GRP_0009_659
# Proprietary July 2020 24516_1_24517_1Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021-12/31/2021
LEE COUNTY BOARD OF COUNTY COMMISSIONERS: Aetna Choice®
POS II Coverage for: Individual + Family | Plan Type: POS
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only
a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1-
800-370-4526. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-370-4526 to request a copy.
Important Questions Answers Why This Matters:
Generally, you must pay all of the costs from providers up to the deductible amount
What is the overall In Network Individual $0 /Family $0. Out-of- before this plan begins to pay. If you have other family members on the plan, each
deductible? Network: Individual $500 / Family $1,000. family member must meet their own individual deductible until the total amount of
deductible expenses paid by all family members meets the overall family deductible.
This plan covers some items and services even if you haven't yet met the deductible
Are there services covered amount. But a copayment or coinsurance may apply. For example, this plan covers
Yes. Emergency care is covered before you
before you meet your certain preventive services without cost sharing and before you meet your deductible.
meet your deductible.
deductible? See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/
Are there other deductibles
No. You don’t have to meet deductibles for specific services.
for specific services?
In-Network: Individual $1,500 / Family $3,000. The out–of–pocket limit is the most you could pay in a year for covered services. If you
What is the out-of-pocket
Out-of-Network: Individual $2,000 / Family have other family members in this plan, they have to meet their own out–of–pocket
limit for this plan?
$4,000. limits until the overall family out–of–pocket limit has been met.
Premiums, balance-billing charges, health care
What is not included in the
this plan doesn't cover & penalties for failure to Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
out-of-pocket limit?
obtain pre-authorization for services.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
Will you pay less if you use a Yes. See www.aetna.com/docfind or call 1-800- receive a bill from a provider for the difference between the provider's charge and what
network provider? 370-4526 for a list of in-network providers. your plan pays (balance billing). Be aware, your network provider might use an out-of-
network provider for some services (such as lab work). Check with your provider
before you get services.
Do you need a referral to see
No. You can see the specialist you choose without a referral.
a specialist?
ProprietaryAll copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
In-Network Out-of-Network
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Provider Provider
Event Information
(You will pay the (You will pay the
least) most)
$10 copay/visit,
Primary care visit to treat an injury or illness deductible doesn't 30% coinsurance None
apply
$35 copay/visit,
If you visit a health
Specialist visit deductible doesn't 30% coinsurance None
care provider’s
apply
office or clinic
You may have to pay for services that aren't
preventive. Ask your provider if the services
Preventive care /screening /immunization No charge 30% coinsurance
needed are preventive. Then check what your
plan will pay for.
$35 copay/visit,
Diagnostic test (x-ray, blood work) deductible 30% coinsurance None
doesn't apply
If you have a test
$50 copay/visit,
Imaging (CT/PET scans, MRIs) deductible 30% coinsurance Prior Authorization Required.
doesn't apply
If you need drugs Copay/prescription,
to treat your deductible doesn't
Generic drugs Not covered Covers 30 day supply (retail), 31-90 day supply
illness or apply: $10 (retail),
$0 (mail order) (mail order). Includes contraceptive drugs &
condition
devices obtainable from a pharmacy, oral &
Copay/prescription,
injectable fertility drugs. No charge for preferred
More information deductible doesn't
Preferred brand drugs Not covered generic FDA-approved women's contraceptives
about prescription apply: $20 (retail),
in-network. Maintenance drugs- no refill
drug coverage is $40 (mail order)
restrictions or penalties apply. Members save
available at Copay/prescription, with lower copays at CVS Caremark® Mail
www.aetnapharmac deductible doesn't
Non-preferred brand drugs Not covered Service Pharmacy or CVS Pharmacy.
y.com/premierplus apply: $35 (retail),
$70 (mail order)
ProprietaryWhat You Will Pay
In-Network Out-of-Network
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Provider Provider
Event Information
(You will pay the (You will pay the
least) most)
Applicable cost as
noted above for All prescriptions must be filled through the Aetna
Specialty drugs Not covered
generic or brand Specialty Pharmacy Network.
drugs
$200 copay/visit,
If you have Facility fee (e.g., ambulatory surgery center) deductible 30% coinsurance None
outpatient surgery doesn't apply
Physician/surgeon fees No charge 30% coinsurance None
$150 copay/visit, $150 copay/visit
Emergency room care deductible doesn't deductible doesn't No coverage for non-emergency use.
apply apply
If you need
Non-emergency transport: not covered, except if
immediate medical Emergency medical transportation No charge No charge
pre-authorized.
attention
$50 copay/visit,
Urgent care deductible doesn't 30% coinsurance No coverage for non-urgent use.
apply
$500 copay/stay, 30% coinsurance
Penalty of $500 for failure to obtain pre-
If you have a Facility fee (e.g., hospital room) deductible doesn't after $500
authorization for out-of-network care.
hospital stay apply copay/stay
Physician/surgeon fees No charge 30% coinsurance None
Office & other
outpatient services: Office & other
If you need mental Outpatient services $10 copay/visit, outpatient services: None
health, behavioral deductible doesn't 30% coinsurance
health, or apply
substance abuse
services $500 copay/stay, 30% coinsurance
Penalty of $500 for failure to obtain pre-
Inpatient services deductible doesn't after $500
authorization for out-of-network care.
apply copay/stay
Office visits No charge 30% coinsurance
If you are pregnant
Childbirth/delivery professional services No charge 30% coinsurance
ProprietaryWhat You Will Pay
In-Network Out-of-Network
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Provider Provider
Event Information
(You will pay the (You will pay the
least) most)
Cost sharing does not apply for preventive
services. Maternity care may include tests and
$500 copay/stay, 30% coinsurance
services described elsewhere
Childbirth/delivery facility services deductible doesn't after
in the SBC (i.e. ultrasound.) Penalty of $500 for
apply $500 copay/stay
failure to obtain pre-authorization for
out-of-network care may apply.
120 visits/calendar year. Penalty of $500 for
Home health care No charge 50% coinsurance failure to obtain pre-authorization for out-of-
network care.
$35 copay/visit,
80 visits/calendar year for Physical, Occupational
Rehabilitation services deductible doesn't 30% coinsurance
& Speech Therapy combined.
apply
$35 copay/visit,
Habilitation services deductible doesn't 30% coinsurance Limited to children up to age 18 for Autism.
apply
If you need help
recovering or have $500 copay/stay, 30% coinsurance 120 days/calendar year. Penalty of $400 for
other special Skilled nursing care deductible doesn't after $500 failure to obtain pre-authorization for out-of-
health needs apply copay/stay network care.
Limited to 1 durable medical equipment for
Durable medical equipment No charge 30% coinsurance same/similar purpose. Excludes repairs for
misuse/abuse.
30% coinsurance
$500 copay/stay,
after $500
deductible doesn't
copay/stay for Penalty of $500 for failure to obtain pre-
Hospice services apply for inpatient;
inpatient; 30% authorization for out-of-network care.
no charge for
coinsurance for
outpatient
outpatient
Children's eye exam No charge Not covered 1 routine eye exam/12 months.
If your child needs
Children's glasses Not covered Not covered Not covered.
dental or eye care
Children's dental check-up Not covered Not covered Not covered.
ProprietaryExcluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture • Dental care (Adult & Child) • Non-emergency care when traveling outside the U.S.
• Bariatric surgery • Glasses (Child) • Routine foot care
• Cosmetic surgery • Long-term care • Weight loss programs - Except for required preventive
services.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care - 20 visits/calendar year. • Infertility treatment - For more information & • Routine eye care (Adult) - 1 routine eye exam/12 months
• CVS Minute Clinic Benefit Program exceptions, see policy document provided by for in-network only.
• Hearing aids - $2,500 maximum/36 months. your employer. • Teladoc Services are included
• Private-duty nursing - 70- 8 hour
shifts/calendar year combined with home
health care.
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
• For more information on your rights to continue coverage, contact the plan at 1-800-370-4526.
• If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272)
or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should
contact their State insurance regulator regarding their possible rights to continuation coverage under State law.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information
about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a
claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
• Aetna directly by calling the toll free number on your Medical ID Card, or by calling our general toll free number at 1-800-370-4526.
• If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA
Proprietary(3272) or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• Additionally, a consumer assistance program can help you file your appeal. Contact information is at:
http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
ProprietaryAbout these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
The plan's overall deductible $0 The plan's overall deductible $0 The plan's overall deductible $0
Specialist copayment $0 Primary care physician copayment $10 Emergency room copayment $150
Childbirth/Delivery(mother) facility copay $500 Diagnostic tests copayment $35 Diagnostic tests copayment $35
Childbirth/Delivery(newborn)facility copay$500 Other copayment $10 Rehabilitation services copayment $35
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Total Example Cost $12,800 Total Example Cost $900 Total Example Cost $4,900
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $1000 Copayments $55 Copayments $220
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn't covered What isn't covered What isn't covered
Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $1000 The total Joe would pay is $55 The total Mia would pay is $220
Proprietary
The plan would be responsible for the other costs of these EXAMPLE covered services.Assistive Technology Persons using assistive technology may not be able to fully access the following information. For assistance, please call 866-393-0002. Smartphone or Tablet To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store. Non-Discrimination Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. We provide free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: P.O. Box 24030, Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD). Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates. Proprietary
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2021-12/31/2021
LEE COUNTY BOARD OF COUNTY COMMISSIONERS: Aetna Open
Access® Aetna SelectSM Coverage for: Individual + Family | Plan Type: EPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only
a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1-
800-370-4526. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-370-4526 to request a copy.
Important Questions Answers Why This Matters:
What is the overall See the Common Medical Events chart below for your costs for services this plan
Network: Individual $0/ Family $0
deductible? covers.
Are there services covered
before you meet your No.
deductible?
Are there other deductibles
No. You don’t have to meet deductibles for specific services.
for specific services?
The out–of–pocket limit is the most you could pay in a year for covered services. If you
What is the out-of-pocket
In-Network: Individual $1,500 / Family $3,000. have other family members in this plan, they have to meet their own out–of–pocket
limit for this plan?
limits until the overall family out–of–pocket limit has been met.
What is not included in the Premiums, balance-billing charges & health
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
out-of-pocket limit? care this plan doesn't cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
Will you pay less if you use a Yes. See www.aetna.com/docfind or call 1-800- receive a bill from a provider for the difference between the provider's charge and what
network provider? 370-4526 for a list of in-network providers. your plan pays (balance billing). Be aware, your network provider might use an out-of-
network provider for some services (such as lab work). Check with your provider
before you get services.
Do you need a referral to see
No. You can see the specialist you choose without a referral.
a specialist?
1 of 6
ProprietaryAll copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
In-Network Out-of-Network
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Provider Provider
Event Information
(You will pay the (You will pay the
least) most)
Primary care visit to treat an injury or illness $10 copay/visit Not covered None
Specialist visit $25 copay/visit Not covered None
If you visit a health
care provider’s You may have to pay for services that aren't
office or clinic preventive. Ask your provider if the services
Preventive care /screening /immunization No charge Not covered
needed are preventive. Then check what your
plan will pay for.
Diagnostic test (x-ray, blood work) $25 copay/visit Not covered None
If you have a test
Imaging (CT/PET scans, MRIs) $50 copay/visit Not covered Prior Authorization Required.
If you need drugs Copay/prescription: Covers 30 day supply (retail), 31-90 day supply
to treat your Generic drugs $10 (retail), $0 (mail Not covered (mail order). Includes contraceptive drugs &
illness or order) devices obtainable from a pharmacy, oral &
condition Copay/prescription: injectable fertility drugs. No charge for preferred
Preferred brand drugs $20 (retail), $40 Not covered generic FDA-approved women's contraceptives
More information (mail order) in-network. Maintenance drugs- no refill
about prescription Copay/prescription: restrictions or penalties apply. Members save
drug coverage is Non-preferred brand drugs $35 (retail), $70 Not covered with lower copays at CVS Caremark® Mail
available at (mail order) Service Pharmacy or CVS Pharmacy.
www.aetnapharmac Applicable cost as
y.com/premierplus noted above for All prescriptions must be filled through the Aetna
Specialty drugs Not covered
generic or brand Specialty Pharmacy Network.
drugs
If you have Facility fee (e.g., ambulatory surgery center) $200 copay/visit Not covered None
outpatient surgery Physician/surgeon fees No charge Not covered None
Emergency room care $150 copay/visit $150 copay/visit No coverage for non-emergency use.
If you need
Non-emergency transport: not covered, except if
immediate medical Emergency medical transportation No charge No charge
pre-authorized.
attention
Urgent care $50 copay/visit Not covered No coverage for non-urgent use.
Facility fee (e.g., hospital room) $500 copay/stay Not covered None
2 of 6
ProprietaryWhat You Will Pay
In-Network Out-of-Network
Common Medical Limitations, Exceptions, & Other Important
Services You May Need Provider Provider
Event Information
(You will pay the (You will pay the
least) most)
If you have a
Physician/surgeon fees No charge Not covered None
hospital stay
If you need mental Office & other
health, behavioral Outpatient services outpatient services: Not covered None
health, or $10 copay/visit
substance abuse $500 copay/stay,
services Inpatient services Not covered None
per member
Office visits No charge Not covered Cost sharing does not apply for preventive
Childbirth/delivery professional services No charge Not covered services. Maternity care may include tests and
If you are pregnant
$500 copay/stay, services described elsewhere in the SBC (i.e.
Childbirth/delivery facility services Not covered ultrasound.)
per member
120 visits/calendar year, including up to 70- 8
Home health care No charge Not covered
hour shifts for private-duty nursing.
80 visits/calendar year for Physical, Occupational
Rehabilitation services $25 copay/visit Not covered
& Speech Therapy combined.
If you need help Habilitation services $25 copay/visit Not covered Limited to treatment of Autism up to age 18.
recovering or have Skilled nursing care $500 copay/stay Not covered 120 days/calendar year.
other special Limited to 1 durable medical equipment for
health needs Durable medical equipment No charge Not covered same/similar purpose. Excludes repairs for
misuse/abuse.
$500 copay/stay for
Hospice services inpatient; no charge Not covered None
for outpatient
Children's eye exam No charge Not covered 1 routine eye exam/12 months.
If your child needs
Children's glasses Not covered Not covered Not covered.
dental or eye care
Children's dental check-up Not covered Not covered Not covered.
Proprietary
3 of 6Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture • Dental care (Adult & Child) • Non-emergency care when traveling outside the U.S.
• Bariatric surgery • Glasses (Child) • Routine foot care
• Cosmetic surgery • Long-term care • Weight loss programs - Except for required preventive
services.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care - 20 visits/calendar year. • Infertility treatment - For more information & • Routine Eye Care (Adult) - 1 routine eye exam/12 months.
• CVS Minute Clinic Benefit Program exceptions, see policy document provided by • Teladoc Services are included
• Hearing Aids - $2,500 maximum/36 months. your employer.
• Private-duty nursing - Included as part of
home health care.
Your Rights to Continue Coverage:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
• For more information on your rights to continue coverage, contact the plan at 1-800-370-4526.
• If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272)
or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should
contact their State insurance regulator regarding their possible rights to continuation coverage under State law.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights:
There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information
about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a
claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
• Aetna directly by calling the toll free number on your Medical ID Card, or by calling our general toll free number at 1-800-370-4526.
4 of 6
Proprietary• If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• Additionally, a consumer assistance program can help you file your appeal. Contact information is at:
http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
5 of 6
ProprietaryAbout these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
The plan's overall deductible $0 The plan's overall deductible $0 The plan's overall deductible $0
Specialist copayment(facility) $0 Primary care physician copayment $10 Emergency room copayment $150
Childbirth/Delivery(mother)facility copay $500 Diagnostic tests copayment $25 Diagnostic tests copayment $25
Childbirth/Delivery(newborn)facility copay$500 Other copayment $10 Rehabilitation services copayment $25
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)
Total Example Cost $12,800 Total Example Cost $900 Total Example Cost $4,900
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments($500 mother/$500 baby) $1000 Copayments $45 Copayments $200
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn't covered What isn't covered What isn't covered
Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $1000 The total Joe would pay is $45 The total Mia would pay is $200
Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce
your costs. For more information about the wellness program, please contact: 1-800-370-4526.
Proprietary
The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 6You can also read
