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%
If you need help recovering or have other special health needs 0% 20% 120 visits/calendar year. Penalty of $400 per occurrence for failure to obtain for out-of-network care. $15 /visit, doesn't apply 20% 60 visits/calendar year for Physical, Occupational & Speech Therapy combined. Includes treatment of Autism. $15 /visit, doesn't apply 20% $100 /stay, doesn't apply 20% 90 days/calendar year. Penalty of $400 per occurrence for failure to obtain for out-of-network care. No charge 20% Limited to 1 for same/similar purpose. Excludes repairs for misuse/abuse. 0% 20% Penalty of $400 per occurrence for failure to obtain for out-of-network care. If your child needs dental or eye care Children's eye exam Not covered Not covered Not covered. Children's glasses Not covered Not covered Not covered. Children's dental check-up Not covered Not covered Not covered. Excluded Services & Other Covered Services: Services Your Generally Does NOT Cover (Check your policy or document for more information and a list of any other .) Acupuncture Bariatric surgery Cosmetic surgery Dental care (Adult & Child) Glasses (Child) Long-term care Non-emergency care when traveling outside the U.S. Routine eye care (Adult & Child) Routine foot care Weight loss programs - Except for required preventive services.
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your charge, and many other factors. Focus on the amounts (, and ) and under the . Use this information to compare the portion of costs you might pay under different health . Please note these coverage examples are based on self-only coverage. The overall $150 $30 Hospital (facility) $100 Other 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles* $200 Copayments $200 Coinsurance $0 What isn't covered Limits or exclusions $60 The total Peg would pay is $460 The overall $150 $30 Hospital (facility) $100 Other 0% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles* $200 Copayments $800 Coinsurance $0 What isn't covered Limits or exclusions $20 The total Joe would pay is $1,020 The overall $150 $30 Hospital (facility) $100 Other 0% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles* $0 Copayments $200 Coinsurance $0 What isn't covered Limits or exclusions $0 The total Mia would pay is $200