Florida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012

Transcription

1 Florida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan HSA PLAN FEATURES Deductible (per calendar year) $2,500 Individual $5,000 Family Member cost sharing for certain services as indicated in the plan, are excluded from charges to meet the Deductible. The Individual Deductible can only be met when a member is enrolled for self only coverage with no dependent coverage. The Family Deductible can be met by a combination of family members or by any single individual within the family. Once the Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. Member Coinsurance Applies to all expenses unless otherwise stated. Out-of-Pocket Maximum (per calendar year, includes deductible) 20% $5,000 Individual $10,000 Family Only those expenses resulting from the application of deductible, coinsurance percentage, copays and prescription drug cost sharing (not including any penalty amounts) may be used to satisfy the Maximum Out-of-Pocket Limit. Members must continue to pay any penalty amounts after meeting their Maximum Out-of-Pocket Limit. Once any one family member or any combination of family members satisfies the Family Maximum Out-of-Pocket Limit, all family members will be considered as having met their Maximum Outof-Pocket Limit for the remainder of the Calendar year. A Single Maximum Out-of-Pocket Limit only applies to an individual enrolled as a single subscriber. Lifetime Maximum Primary Care Physician Selection Referral Requirement PHYSICIAN SERVICES Unlimited Not Required None Primary Care Physician Visits Specialist Office Visits Maternity OB Visits Primary Care Physician E-Visits An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through an Aetna authorized internet E-visit service vendor. Specialist E-Visits An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through an Aetna authorized internet E-visit service vendor. Walk-in Clinics Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, nonemergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor an outpatient department of a hospital, shall be considered a Walk-in Clinic. Allergy Treatment Allergy Testing FLHPD6 3/11 HO258H v

2 PREVENTIVE CARE Routine Adult Physical Exams / Immunizations One exam every 12 months Well Child Exams / Immunizations 7 exams 1st 12 months, 3 exams 13th - 24th months, 3 exams 25th - 36th months, 1 exam per 12 months thereafter to age 18. Routine Gynecological Care Exams Includes Pap smear and related lab fees. Frequency schedule applies. Routine Mammograms One baseline exam ages 35-39, one per calendar year age 40 and over, or as directed by a physician. Routine Digital Rectal Exam / Prostate Specific Antigen Test For covered males age 40 and over, frequency schedule applies. Routine (or Preventive) Colorectal Cancer Screening Sigmoidoscopy and Double Contrast Barium Enema (DCBE) - 1 every 5 years for all members age 50 and over; Colonoscopy - 1 every 10 years for all members age 50 and over; Fecal Occult Blood Testing (FOBT) - 1 every year for all members age 50 and over. Routine Eye Exams at Specialist 1 exam every 24 months Routine Hearing Screening at PCP Covered only as part of a physical exam. DIAGNOSTIC PROCEDURES Subject to Routine Physical Exam cost sharing. Outpatient Diagnostic Laboratory (If performed as a part of a physician's office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing.) Diagnostic X-ray except for Complex Imaging Services outpatient hospital or other outpatient facility Diagnostic X-ray for Complex Imaging Services (including but not limited to MRI, MRA, PET and CT Scans) EMERGENCY MEDICAL CARE Urgent Care Provider Non-Urgent Use of Urgent Care Provider Emergency Room copay waived if admitted Non-Emergency Care in an Emergency Room Ambulance HOSPITAL CARE Inpatient Coverage Including maternity (prenatal, delivery and postpartum) & transplants Outpatient Surgery Not Covered Not Covered FLHPD6 3/11 HO258H v

3 MENTAL HEALTH SERVICES Inpatient Limited to 30 days per member per calendar year. Outpatient Limited to 20 visits per member per calendar year. ALCOHOL/DRUG ABUSE SERVICES Inpatient Detoxification Outpatient Detoxification Inpatient Rehabilitation Limited to 30 days per member per calendar year. Outpatient Rehabilitation Limited to 45 visits per member per calendar year. MENTAL HEALTH SERVICES (For Employer Groups subject to Federal Mental Health Parity) Inpatient Outpatient ALCOHOL/DRUG ABUSE SERVICES (For Employer Groups subject to Federal Mental Health Parity) Inpatient Detoxification Outpatient Detoxification Inpatient Rehabilitation Outpatient Rehabilitation OTHER SERVICES AND PLAN DETAILS Convalescent Facility (skilled nursing facility) Limited to 60 days per member per calendar year Home Health Care Limited to 60 visits per member per calendar year; 1 visit equals a period of 4 hours or less. Hospice Care Inpatient Hospice Care Outpatient Infusion Therapy Provided in the home or physician's office Infusion Therapy Provided in an outpatient hospital department or freestanding facility Outpatient Short-Term Rehabilitation Limited to 30 visits per member per calendar year. Includes speech, physical and occupational therapy. Subluxation (Chiropractic) Limited to 20 visits per member per calendar year. Durable Medical Equipment Maximum benefit of $2,000 per member per calendar year Diabetic Supplies not obtainable at a pharmacy Prescription drug copay FLHPD6 3/11 HO258H v

4 FAMILY PLANNING Infertility Treatment Coverage only for the diagnosis and treatment of the underlying medical condition. Voluntary Sterilization Including tubal ligation and vasectomy PHARMACY PRESCRIPTION DRUG BENEFITS Member cost sharing is based on the type of service performed and the place rendered. Member cost sharing is based on the type of service performed and the place rendered. Preventive Medications - Deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator TM or from your employer. The deductible applies to all other drugs and the full cost of all other drugs is applied to the deductible before any benefits are considered for payment under the pharmacy plan. Retail Up to a 30 day supply at participating pharmacies. Mail Order Up to 90 day supply at participating pharmacies. $20 copay for generic formulary drugs, $50 copay for brand-name formulary drugs, and $75 copay for nonformulary drugs $40 copay for generic formulary drugs, $100 copay for brand-name formulary drugs, and $150 copay for nonformulary drugs Specialty CareRx 20% copay with a minimum copay of $15 and a maximum copay of $225 per prescription. Specialty CareRx - First Prescription for a specialty drug must be filled at a participating retail pharmacy or Aetna Specialty Pharmacy. Subsequent fills must be through Aetna Specialty Pharmacy. No Mandatory Generic (No MG) Member is responsible to pay the applicable copay only. Plan includes contraceptive drugs and devices obtainable from a pharmacy and diabetic supplies. Precertification included. What s Not Covered This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased. All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents, including costs of services before coverage begins and after coverage terminates. Cosmetic surgery. Custodial care. Dental care and dental x-rays. Donor egg retrieval. Experimental and investigational procedures (except for coverage for medically necessary routine patient care costs for Members participating in a cancer clinical trial). Hearing aids. Home births. Immunizations for travel or work. Implantable drugs and certain injectable drugs including injectable infertility drugs. Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents. Nonmedically necessary services or supplies. Orthotics. Over-the-counter medications and supplies. Radial keratotomy or related procedures. Reversal of sterilization. Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies, counseling, and prescription drugs. Special duty nursing. Therapy or rehabilitation other than those listed as covered in the plan documents. Treatment of behavioral disorders. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. FLHPD6 3/11 HO258H v

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