PEBB - Aetna Public Employees Plan

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Aetna Public Employees Plan

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Benefit Summary

Contact Information

Toll-Free Phone: 1-800-222-9205
TTY/TDD Phone: 1-800-628-3323
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Benefit Summary

Medical Benefit	Coverage
Lifetime maximum	None
Annual deductible	None
Annual out-of-pocket maximum	Enrollee pays $750 per person/$1,500 per family (Expenses as defined in the Certficate of Coverage do not count toward the out-of-pocket maximum.)
Office and clinic visits	$10 copay per visit
Ambulance services
(air)	$100 copay per trip
(ground)	$75 copay per trip
Bariatric Surgery (preauthorization required)	Must be accepted into presurgical program; can only use plan-designated providers. Covered at same level as for other professional services, inpatient/outpatient hospital services, and tests.
Chemical dependency services (inpatient) (Maximum payment for all plans is $14,000 per 24 consecutive calendar month period for any combination of inpatient/outpatient treatment)	Enrollee pays inpatient hospital copay; preauthorization required
Chemical dependency services (outpatient)	$10 copay per visit
Diabetic education	$10 copay per visit; limited to 10 visits per year
Diagnostic testing	$10 copay per visit to diagnostic imaging facilities Covered in full if part of an office visit
Durable medical equipment, supplies, and prostheses	Enrollee pays 20% coinsurance (not subject to annual deductible)
Emergency room (copay waived if admitted directly to hospital)	$75 copay per visit
Hearing
(examination)	Covered in full under preventive care benefit; one exam per calendar year
(hardware)	Maximum plan payment of $400 every three calendar years for hearing aid, and rental/repair combined
Home health care	Covered in full
Hospice care (including respite care)	Covered in full; respite care is limited to five days per three-month period
Hospital services
(inpatient)	$200 copay per day (maximum $600 per person per calendar year)
(outpatient)	$100 copay for facility fees per surgery or procedure; surgeon, anesthesiologist, etc., covered in full
Massage therapy	$10 copay per visit; up to 16 visits per calendar year
Mental health care
(inpatient)	Enrollee pays inpatient hospital copay; preauthorization required
(outpatient)	$10 copay per visit, up to 50 visits per year
Neurodevelopmental therapy (for children ages 6 and younger)
(inpatient)	Included in physical, occupational, and speech therapy benefit
(outpatient)	Included in physical, occupational, and speech therapy benefit
Obstetric and well-newborn care
(inpatient)	Enrollee pays inpatient hospital copay for mother only
(professional services)	Covered in full after $10 copay for first visit
Organ transplants
(inpatient)	Enrollee pays inpatient hospital copay; preauthorization required
(professional)	Covered in full; preauthorization required No limit on number of donor searches
Physical, occupational, speech, and massage therapies
(inpatient)	Does not include massage therapy (see massage therapy benefit) Includes neurodevelopmental therapy Enrollee pays inpatient hospital copay; preauthorization required
(outpatient)	$10 copay per visit, up to 60 visits per calendar year
Prescription drugs, insulin, and disposable diabetic supplies	Retail (up to a 30-day supply): Tier 1 (generic and preferred specialty drugs), $10 copay Tier 2 (preferred brand), $25 copay Tier 3* (nonpreferred brand), $40 copay Mail order (up to a 90-day supply): Tier 1 (generic and preferred specialty drugs), $20 copay Tier 2 (preferred brand), $50 copay Tier 3* (nonpreferred brand), $80 copay *Multi-source Tier 3 drugs are subject to an ancillary charge—the enrollee pays the Tier 1 copay, plus the difference between the Tier 3 drug and the generic equivalent.
Preventive care	Covered in full, subject to preventive care schedule Only services listed in the Certificate of Coverage are covered as preventive care.
Radiation and chemotherapy services	$10 copay per visit
Skilled nursing facility care (150 days per benefit period)	Enrollee pays inpatient hospital copay; covered up to 150 days per calendar year
Spinal manipulations	$10 copay per visit, up to 10 visits per year
Temporomandibular joint (TMJ) disorder	Preauthorized surgical treatment only-enrollee pays inpatient or outpatient copay Non-surgical treatment for TMJ is not covered.
Vision
(examinations)	$10 copay per exam; one annual eye exam
(hardware)	$150 maximum plan payment every two calendar years for frames, lenses, contacts, and fitting fees combined