WALMART : Aetna Open Access Managed Choice - GeC PPO
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan documentat www.HealthReformPlanSBC.com or by calling 1-855-548-2387.Important QuestionsAre there other deductiblesNo.for specific services?Why this Matters:You must pay all the costs up to the deductible amount before this plan beginsto pay for covered services you use. Check your policy or plan document to seewhen the deductible starts over (usually, but not always, January 1st). See thechart starting on page 2 for how much you pay for covered services after youmeet the deductible.You don't have to meet deductibles for specific services, but see the chartstarting on page 2 for other costs for services this plan covers.Is there anout-of-pocket limiton my expenses?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 limithelps you plan for health care expenses.What is the overalldeductible?What is not included inthe out-of-pocket limit?AnswersIn-Network: Individual 500 / Family 1,000.Out–of–Network: Individual 1,000/ Family 2,000. Does not apply to office visits,prescription drugs, emergency care, andpreventive care in-network.Yes. In-Network: Individual 2,500 / Family 5,000. Out–of–Network: Individual 5,000 /Family 10,000.Premiums, balance-billed charges, penaltiesfor failure to obtain pre-authorization forservice, and health care this plan does notcover.Even though you pay these expenses, they don't count toward the out-ofpocket limit.Is there an overallannual limit on whatthe plan pays?No.The chart starting on page 2 describes any limits on what the plan will pay forspecific covered services, such as office visits.Does this plan use anetwork of providers?Yes. See www.aetna.com or call1-855-548-2387 for a list of in-networkproviders.If you use an in-network doctor or other health care provider, this plan will paysome or all of the costs of covered services. Be aware, your in-network doctor orhospital may use an out-of-network provider for some services. Plans use theterm in-network, preferred, or participating for providers in their network. Seethe chart starting on page 2 for how this plan pays different kinds of providers.Do I need a referral tosee a specialist?No.You can see the specialist you choose without permission from this plan.Are there services thisplan doesn't cover?Yes.Some of the services this plan doesn't cover are listed on page 5. See yourpolicy or plan document for additional information about excluded services.Questions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.072100-090020-3415921 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSCopayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service.Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplan's allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change if youhaven't met your deductible.The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay and the allowedamount is 1,000, you may have to pay the 500 difference. (This is called balance billing.)This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts.CommonMedical EventServices You May NeedPrimary care visit to treat an injury orillnessSpecialist visitOther practitioner office visitIf you visit a healthcare provider's officeor clinicIf you have a testYour Cost IfYou Use anIn-Network ProviderYour Cost IfYou Use anOut–of–NetworkProvider 20 copay/visit50% coinsurance 30 copay/visit50% coinsurance 20 copay/visit50% coinsurancePreventive care /screening/immunizationNo chargeDiagnostic test (x-ray, blood work)Imaging (CT/PET scans, MRIs)10% coinsurance10% coinsuranceLimitations & ExceptionsIncludes Internist, General Physician,Family Practitioner or –––––––––––Coverage is limited to 20 visits per calendaryear for Chiropractic care.50% coinsurance;deductible waived forprostate specificantigen tests & digital Age and frequency schedules may apply.rectal exams; no chargefor �none–––––––––––50% �––––––––––50% coinsuranceQuestions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.072100-090020-3415922 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you need drugs totreat your illness orconditionServices You May NeedGeneric drugsMore informationPreferred brand drugsabout prescriptiondrug coverage isavailable atwww.aetna.com/pharmacy-insurance/individ Non-preferred brand drugsuals-familiesPremier Two TierOpen FormularyIf you haveoutpatient surgeryIf you needimmediate medicalattentionSpecialty drugsFacility fee (e.g., ambulatory surgerycenter)Physician/surgeon feesEmergency room servicesEmergency medical transportationUrgent careIf you have a hospital Facility fee (e.g., hospital room)stayPhysician/surgeon feeYour Cost IfYou Use anIn-Network ProviderCopay/prescription: 10 for 30 day supply(retail), 20 for 31-90day supply (retail &mail order)Copay/prescription: 30 for 30 day supply(retail), 60 for 31-90day supply (retail &mail order)Copay/prescription: 30 for 30 day supply(retail), 60 for 31-90day supply (retail &mail order)Coverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSYour Cost IfYou Use anOut–of–NetworkProvider20% coinsurance aftercopay/prescription: 10 (retail)20% coinsurance aftercopay/prescription: 30 (retail)20% coinsurance aftercopay/prescription: 30 (retail)Limitations & ExceptionsCovers 30 day supply (retail), 31-90 daysupply (participating retail & mail order).Includes contraceptive drugs & devicesobtainable from a pharmacy, oral fertilitydrugs. No charge for formulary genericFDA-approved women's contraceptivesin-network. Review your formulary forprescriptions requiring precertification orstep therapy for coverage. Your cost will behigher for choosing Brand over Generics.Applicable cost asnoted above forNot coveredgeneric or brand drugs.First prescription must be filled at aparticipating retail pharmacy or AetnaSpecialty Pharmacy Networks. Subsequentfills must be through Aetna SpecialtyPharmacy Networks.10% coinsurance50% �––––––––––10% coinsurance 50 copay/visit10% coinsurance 50 copay/visit50% coinsurance 50 copay/visit10% coinsurance50% coinsurance10% coinsurance50% coinsurance10% coinsurance50% �––––––––––No coverage for non-emergency use.No coverage for non-emergency ––––––––––Pre-authorization required forout-of-network �––––––––Questions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.072100-090020-3415923 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf you have mentalhealth, behavioralhealth, or substanceabuse needsIf you are pregnantIf you need helprecovering or haveother special healthneedsServices You May NeedYour Cost IfYou Use anIn-Network ProviderCoverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSYour Cost IfYou Use anOut–of–NetworkProviderLimitations & ExceptionsMental/Behavioral health outpatientservicesMental/Behavioral health inpatientservicesSubstance use disorder outpatientservicesSubstance use disorder inpatientservicesPrenatal and postnatal care 30 copay/visit50% �––––––––––10% coinsurance50% coinsurancePre-authorization required forout-of-network care. 30 copay/visit50% �––––––––––10% coinsurance50% coinsuranceNo charge50% coinsuranceDelivery and all inpatient services10% coinsurance50% coinsuranceHome health care 30 copay/visit, afterdeductible50% coinsuranceRehabilitation services 20 copay/visit50% coinsuranceHabilitation services 20 copay/visit50% coinsuranceSkilled nursing care10% coinsurance50% coinsuranceDurable medical equipment10% coinsurance50% coinsuranceHospice service10% coinsurance50% coinsuranceQuestions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.Pre-authorization required forout-of-network �––––––––Includes outpatient postnatal care.Pre-authorization may be required forout-of-network care.Coverage is limited to 60 visits per calendaryear. Pre-authorization required forout-of-network care.Coverage is limited to 20 visits per calendaryear for Physical, Occupational & SpeechTherapy combined.Coverage is limited to Autism Physical,Occupational & Speech Therapy forchildren up to age 18; 20 visits per calendaryear after age 18, combined withrehabilitation services.Coverage is limited to 60 days per calendaryear. Pre-authorization required forout-of-network �––––––––Pre-authorization required forout-of-network care.072100-090020-3415924 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCommonMedical EventIf your child needsdental or eye careYour Cost IfYou Use anIn-Network ProviderServices You May NeedCoverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSYour Cost IfYou Use anOut–of–NetworkProviderEye examNo charge50% coinsuranceGlassesDental check-upNot coveredNot coveredNot coveredNot coveredLimitations & ExceptionsCoverage is limited to 1 routine eye examper 24 months.Not covered.Not covered.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.)AcupunctureCosmetic surgeryDental care (Adult & Child)Glasses (Child)Hearing aidsLong-term careNon-emergency care when traveling outside theU.S.Routine foot careWeight loss programsOther 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 surgeryChiropractic care - Coverage is limited to 20 visitsper calendar year.Infertility treatment - Coverage is limited to thediagnosis and treatment of underlying medicalcondition.Private-duty nursing - Coverage is limited to 60 - 8hour shifts per calendar year.Routine eye care (Adult) - Coverage is limited to 1routine eye exam per 24 months.Your Rights to Continue Coverage:If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep healthcoverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay whilecovered under the plan. Other limitations on your rights to continue coverage may also apply.For more information on your rights to continue coverage, contact the plan at 1-855-548-2387. You may also contact your state insurance department, the U.S.Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and HumanServices at 1-877-267-2323 x61565 or www.cciio.cms.gov.Questions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.072100-090020-3415925 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanSummary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSYour Grievance and Appeals Rights:If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questionsabout your rights, this notice, or assistance, you can contact us by calling the toll free number on your Medical ID Card. If your group health plan is subject toERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform. You may also contact the Arkansas Insurance Department, (501) 371-2600, http://insurance.arkansas.gov.Additionally, a consumer assistance program can help you file your appeal. Contact Arkansas Insurance Department, 1200 West Third St, Little Rock, AR27701, (855) 332-2227, insurance.consumers@arkansas.govDoes this Coverage Provide Minimum Essential Coverage?The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage". This plan or policy does provideminimum essential coverage.Does this Coverage Meet Minimum Value Standard?The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This healthcoverage does meet the minimum value standard for the benefits it provides.Language Access Services:Para obtener asistencia en Español, llame al 1-855-548-2387.1-855-548-2387.Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-548-2387.Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-548-2387.-------------------To see examples of how this plan might cover costs for a sample medical situation, see the next page.-------------------Questions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.072100-090020-3415926 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanCoverage ExamplesAbout these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This is nota costestimator.Don't use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care also will bedifferent.See the next page forimportant information aboutthese examples.Coverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSHaving a babyManaging type 2 diabetes(normal delivery)(routine maintenance ofa well-controlled condition)Amount owed to providers: 7,540Plan pays: 6,320Patient pays: 1,220Sample care costs:Hospital charges (mother)Routine obstetric careHospital charges (baby)AnesthesiaLaboratory testsPrescriptionsRadiologyVaccines, other preventiveTotal 2,700 2,100 900 900 500 200 200 40 7,540Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotal 500 20 500 200 1,220Amount owed to providers: 5,400Plan pays: 4,120Patient pays: 1,280Sample care costs:PrescriptionsMedical Equipment and SuppliesOffice Visits and ProceduresEducationLaboratory testsVaccines, other preventiveTotal 2,900 1,300 700 300 100 100 5,400Patient pays:DeductiblesCopaysCoinsuranceLimits or exclusionsTotalQuestions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy. 500 600 100 80 1,280072100-090020-3415927 of 8
:WALMART : Aetna Open Access Managed Choice - GeC PPOPlanCoverage ExamplesCoverage Period: 01/01/2016 - 12/31/2016Coverage for: Individual Family Plan Type: POSQuestions and answers about the Coverage Examples:What are some of the assumptionsbehind the Coverage Examples?Costs don't include premiums.Sample care costs are based on nationalaverages supplied by the U.S. Departmentof Health and Human Services, and aren'tspecific to a particular geographic area orhealth plan.The patient's condition was not anexcluded or preexisting condition.All services and treatments started andended in the same coverage period.There are no other medical expenses forany member covered under this plan.Out-of-pocket expenses are based only ontreating the condition in the example.The patient received all care fromin-network providers. If the patient hadreceived care from out-of-networkproviders, costs would have been higher.What does a CoverageExample show?Can I use Coverage Examples tocompare plans?Yes. When you look at the Summary ofFor each treatment situation, the CoverageExample helps you see how deductibles,copayments, and coinsurance can add up. Italso helps you see what expenses might be leftup to you to pay because the service ortreatment isn't covered or payment is limited.Does the Coverage Examplepredict my own care needs?No. Treatments shown are just examples.Benefits and Coverage for other plans,you'll find the same Coverage Examples.When you compare plans, check the "PatientPays" box in each example. The smaller thatnumber, the more coverage the planprovides.Are there other costs I shouldconsider when comparing plans?The care you would receive for thiscondition could be different, based on yourdoctor's advice, your age, how serious yourcondition is, and many other factors.Does the Coverage Examplepredict my future expenses?No. Coverage Examples are not costestimators. You can't use the examples toestimate costs for an actual condition. Theyare for comparative purposes only. Yourown costs will be different depending onthe care you receive, the prices yourproviders charge, and the reimbursementyour health plan allows.Questions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com.If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.HealthReformPlanSBC.com or call 1-855-548-2387 to request a copy.Yes. An important cost is the premiumyou pay. Generally, the lower yourpremium, the more you'll pay inout-of-pocket costs, such as copayments,deductibles, and coinsurance. You shouldalso consider contributions to accounts suchas health savings accounts (HSAs), flexiblespending arrangements (FSAs) or healthreimbursement accounts (HRAs) that helpyou pay out-of-pocket expenses.072100-090020-3415928 of 8
See www.aetna.com or call 1-855-548-2387 for a list of in-network providers. . 01/01/2016 - 12/31/2016 Questions: Call 1-855-548-2387 or visit us at www.HealthReformPlanSBC.com. . Review your formulary for prescriptions requiring precertification or step therapy for coverage. Y
aetna health and life insurance company aetna health management, llc aetna health plans aetna life insurance company aetna rural program / aetna aetna rural program / aetna pos/epo aetna wp pricing affiliated of florida affinity group underwriters, inc. affordable benefit administrators, inc. afs
OA Managed Choice POS. OA Managed Choice POS HDHP. Open Choice PPO. Open Choice PPO HDHP. Savings Plus OA Managed Choice POS. Savings Plus OA Managed Choice POS HDHP. Aetna.com . 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 .
by Aetna Health Inc., Aetna Health of California Inc. and/or Aetna Life Insurance Company (Aetna). This is a brief description of the features of these Aetna health benefits plans. Before making a decision, please read the plan's applicable federal brochure(s). All benefits are subject to the definitions, limitations and
outside of the Aetna Whole Health network, but within another Aetna network, they may still be able to see doctors in the Aetna network where they live. Out-of-area option: If your dependents live outside of the Aetna Whole Health network or any similar Aetna network, they may still get access to on
This emergency leave policy compounds long-standing problems with Walmart's leave policies. Data from UC Berkeley's Shift Project before the pandemic, showed 347,000 Walmart associates did not believe they had access to paid sick leave from their employer.11 A national survey of Walmart associates found that 88% of Walmart associates
SCHOOL EMPLOYEES RETIREMENT SYSTEM OF OHIO : Aetna Choice POS II - HCPII Coverage Period: 01/01/2021-12/31/2021 . 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 .File Size: 1MBPage Count: 11Explore furtherAetna Choice POS II - Discontinued as of Jan 1, 2021 .postdocbenefits.stanford.eduAetna Choice POS II Summary of Benefitswww.aetna.comAetna Choice POS II Medical Plan - Marine Corps Communityusmc-mccs.orgPrescription Drug List (Formulary), Coverage . - Aetnawww.aetna.comBENEFIT PLAN What Your Plan Covers and How - Aetnawww.aetna.comRecommended to you b
Aetna Health Insurance Company of New York is a subsidiary of Aetna Inc., a publicly traded company. AHIC's business is composed solely of out-of-network POS business generated on products issued by its HMO affiliate, Aetna Health Inc. (a New York Corporation) (Aetna
Welcome to Aetna Better Health of Ohio Inc., an Ohio corporation, d/b/a Aetna Better Health of Ohio, the OhioRISE plan. Our ability to provide excellent service to our members is dependent on the quality of our provider network. By joining our network, you are helping us serve those Ohioans who need us most. About Aetna Better Health Aetna .
