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Summary of Benefits and Coverage: Aetna Silver $20 Copay $5950

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Summary of Benefits and Coverage: Aetna Silver $20 Copay $5950 : Aetna Silver $20 Copay $5950 PPO Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO This 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 document at https://www.aetna.com/sbcsearch/getcbpolicydocs?P=0718482&Y=17 or by calling 1-844-241-0208. Important Questions Answers Why this Matters: In-network: Individual $5,950 / Family You must pay all the costs up to the deductible amount before this plan begins $11,900. Out-of-network: Individual $10,000 / to pay for covered services you use. Check your policy or plan document to see What is the overall Family $20,000. Does not apply to certain when the deductible starts over (usually, but not always, January 1st). See the deductible? office visits, preventive care and urgent care chart starting on page 2 for how much you pay for covered services after you in-network. meet the deductible. Are there other You don’t have to meet deductibles for specific services, but see the chart deductibles for specific No. starting on page 2 for other costs for services this plan covers. services? Yes. In-network: Individual $5,950 / Family The out-of-pocket limit is the most you could pay during a coverage period Is there an out-of-pocket $11,900. Out-of-network: Individual (usually one year) for your share of the cost of covered services. This limit helps limit on my expenses? Unlimited / Family Unlimited. you plan for health care expenses. Premiums, balance-billed charges, penalties for What is not included in Even though you pay these expenses, they don’t count toward the out-of failure to obtain pre-authorization for services, the out-of-pocket limit? pocket limit. and health care this plan does not cover. Is there an overall annual The chart starting on page 2 describes any limits on what the plan will pay for limit on what the plan No. specific covered services, such as office visits. pays? If you use an in-network doctor or other health care provider, this plan will pay Yes. See www.aetna.com or call some or all of the costs of covered services. Be aware, your in-network doctor Does this plan use a 1-844-241-0208 for a list of in-network or hospital may use an out-of-network provider for some services. Plans use the network of providers? providers. term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to see No. You can see the specialist you choose without permission from this plan. a specialist? Are there services this Some of the services this plan doesn’t cover are listed on page 6. See your policy Yes. plan doesn't cover? or plan document for additional information about excluded services. Questions: Call 1-844-241-0208 or visit us at www.HealthReformPlanSBC.com. 071500-090020-521695 If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at 1 of 8 www.HealthReformPlanSBC.com or call 1-844-241-0208 to request a copy. : Aetna Silver $20 Copay $5950 PPO Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO • Copayments 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 the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven'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 allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount 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. Your Cost If Your Cost If Common You Use an You Use an Services You May Need Limitations & Exceptions Medical Event In-Network Out–of–Network Provider Provider $20 copay/visit, –––––––––––none––––––––––– Primary care visit to treat an injury or 50% coinsurance, deductible does not illness after deductible apply $75 copay/visit, –––––––––––none––––––––––– 50% coinsurance, Specialist visit deductible does not after deductible apply If you visit a health 0% coinsurance, after 25% coinsurance, Coverage is limited to 30 visits for care provider’s office Other practitioner office visit deductible for after deductible for Chiropractic care. or clinic Chiropractic care Chiropractic care 50% coinsurance, Age and frequency schedules may apply. after deductible; Preventive care /screening except deductible No charge /immunization does not apply for childhood immunizations 0% coinsurance, after 50% coinsurance, –––––––––––none––––––––––– Diagnostic test (x-ray, blood work) deductible after deductible If you have a test 0% coinsurance, after 50% coinsurance, Out-of-network precertification required or Imaging (CT/PET scans, MRIs) deductible after deductible $400 penalty applies per occurrence. Questions: Call 1-844-241-0208 or visit us at www.HealthReformPlanSBC.com. 071500-090020-521695 If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at 2 of 8 www.HealthReformPlanSBC.com or call 1-844-241-0208 to request a copy. : Aetna Silver $20 Copay $5950 PPO Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO Your Cost If Your Cost If Common You Use an You Use an Services You May Need Limitations & Exceptions Medical Event In-Network Out–of–Network Provider Provider Tier 1A: $5 copay for Covers up to a 30 day supply (retail up to a 30 day supply, prescription), 31-90 day supply (retail & $15 copay for up to a mail order prescription). Applicable cost 50% coinsurance for 90 day supply; Tier 1: share plus difference (brand minus generic If you need drugs to up to a 30 day Preferred generic drugs $12 copay for up to a cost) applies for brand when generic treat your illness or supply, deductible 30 day supply, $36 available. No charge for preferred generic condition does not apply copay for up to a 90 FDA-approved women's contraceptives day supply, deductible in-network. Precertification and step More information does not apply therapy required. No coverage for mail about prescription 0% coinsurance, after 50% coinsurance, order prescriptions out-of-network. drug coverage is Preferred brand drugs deductible for up to a after deductible for available at 90 day supply up to a 30 day supply http://client.formularyn 0% coinsurance, after 50% coinsurance, avigator.com/Search.asp Non-preferred generic/brand drugs deductible for up to a after deductible for x?siteCode=5644738991 90 day supply up to a 30 day supply All specialty prescription drug fills on Five Tier Closed initial fill must be filled at a network 0% coinsurance, after Individual Formulary Preferred specialty drugs, non-preferred specialty pharmacy except for urgent deductible for up to a Not covered specialty drugs situations. Your plan may include access to 30 day supply CVS retail pharmacies for certain specialty drugs. Facility fee (e.g., ambulatory surgery 0% coinsurance, after 50% coinsurance, –––––––––––none––––––––––– If you have outpatient center) deductible after deductible surgery 0% coinsurance, after 50% coinsurance, –––––––––––none––––––––––– Physician/surgeon fees deductible after deductible Questions: Call 1-844-241-0208 or visit us at www.HealthReformPlanSBC.com. 071500-090020-521695 If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at 3 of 8 www.HealthReformPlanSBC.com or call 1-844-241-0208 to request a copy. : Aetna Silver $20 Copay $5950 PPO Coverage Period: 01/01/2017 - 12/31/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family|Plan Type: PPO Your Cost If Your Cost If Common You Use an You Use an Services You May Need Limitations & Exceptions Medical Event In-Network Out–of–Network Provider Provider Out-of-network emergency room services 0% coinsurance, after 0% coinsurance, Emergency room services cost-share same as in-network. No deductible after deductible coverage for non-emergency care. If you need 0% coinsurance, after 0% coinsurance, Out-of-network cost-share same as immediate medical Emergency medical transportation deductible after deductible in-network. attention $75 copay/visit, No coverage for non-urgent use. 50% coinsurance, Urgent care deductible does not after deductible apply 0% coinsurance, after 50% coinsurance, Out-of-network precertification required or Facility fee (e.g., hospital room) If you have a hospital deductible after deductible $400 penalty applies per occurrence. stay 0% coinsurance, after 50% coinsurance, –––––––––––none––––––––––– Physician/surgeon fee deductible after deductible $75 copay/visit, –––––––––––none––––––––––– Mental/Behavioral health outpatient 50% coinsurance, deductible does not services after deductible apply If you have mental Mental/Behavioral health inpatient 0% coinsurance, after 50% coinsurance, Out-of-network precertification required or health, behavioral services deductible after deductible $400 penalty applies per occurrence.
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