Health+Savings Out-of-Area (OOA) Option summary chart

The Health+Savings OOA Option is available only if you live in an area where the Aetna Choice POS II network is not available. In addition to the option described below, you may want to consider the HealthPlus and Standard OOA Options.

If you participate in a PPO Option, see the PPO Options (HealthPlus and Standard) summary chart or the Health+Savings PPO Option summary chart.


 
Health+Savings OOA Optiona,b
2019/2020 Plan Year
General information  
Plan year deductiblec

See Deductibles for more information
$1,500 if you have You Only coverage;
 $3,000 if you have You + Spouse, You + Child(ren) or You + Family coverage
Plan year out-of-pocket maximumc

See Out-of-pocket maximums for more information
$3,000 if you have You Only coverage;
 $6,000 if you have You + Spouse, You + Child(ren) or You + Family coverage
Lifetime maximum benefit None
Prescription drug (administered by Express Scripts)  
Prescription drug plan year deductible (separate from and in addition to your medical plan deductible) No separate deductible
FDA-approved women’s contraception and generic and OTC bowel prep medications for colonoscopy 100%; no deductible or copay
Retail Pharmacy Network (up to a 30-day supply)
Note: Prescriptions purchased at an out-of-network pharmacy are covered only if a network pharmacy is not available.
Generic
After medical deductible is met, 100% after $5 copay, except for generic preventive covered at 100% with no copay or deductible
Brand name (preferred)
After medical deductible is met, 100% after $25 copay
Brand name (non-preferred)
After medical deductible is met, 100% after $45 copay
Brand name (when generic is available) After medical deductible is met, brand name copay plus the difference in cost between the brand name and the equivalent generic
Home Delivery Program (up to a 90-day supply)    
Generic
After medical deductible is met, 100% after $12 copay, except for generic preventive covered at 100% with no copay or deductible
Brand name (preferred)
 
After medical deductible is met, 100% after $65 copay
Brand name (non-preferred)
After medical deductible is met, 100% after $125 copay
Brand name (when generic is available) After medical deductible is met, brand name copay plus the difference in cost between the brand name and the equivalent generic
For the following covered treatments and services, the Health+Savings OOA Option pays
Doctor visits (other than preventive care)d
Primary care office visit 100% after $20 copay, after deductiblee
Note:  surgery is covered at 80% after deductible
Specialist office visit 100% after $30 copay, after deductiblee
Note:  surgery is covered at 80% after deductible
Behavioral health office visit 100% after $20 copay, after deductiblee
Maternity services 100%, no deductible/copay (prenatal); 80% after deductible (post-natal)
Lab and X-ray 80%e
Preventive cared,f
Routine physicalsg 100%, no copay, no deductible
Annual well-woman examg 100%, no copay, no deductible
Mammograms (routine) 100%, no copay, no deductible
Gestational diabetes screening 100%, no copay, no deductible
Prostate Specific Antigen (PSA) tests (routine) 100%, no copay, no deductible
Colorectal screenings (routine) 100%, no copay, no deductible
Well-child care (routine)g 100%, no copay, no deductible
Emergency servicesd
Emergency room (applies to facility charges only) 80% after $150 copay, after deductible
Ambulance 80%
Urgent care facility (applies to facility charges only) 100% after $30 copay, after deductible
Outpatient servicesd (services provided other than in a doctor's office)   
Outpatient surgery facility 80%
Hospital outpatient services 80%
Doctor/surgeon and related professional fees 80%
Behavioral health outpatient treatment (other than office visit)h 80%
Lab and X-ray 80%
Radiation therapy/chemotherapy 80%
Inpatient hospital servicesd
Room and board (semi-private room)h 80%
Inpatient behavioral health stay, including residential treatment and partial hospitalizationh 80%
Doctor hospital visits 80%
Lab, X-ray and anesthesia 80%
Alternatives to inpatient hospital cared
Skilled nursing facility (up to 60 days/plan year)h 80%
Home health care (limited to 120 visits/plan year)h 80%
Hospice careh 80%
Outpatient private duty nursing (up to 70 shifts/plan year)h 80%
Other covered servicesd
Chiropractic care (including lab/X-ray provided by a chiropractor); up to 20 visits/plan year 80%
Contraceptive administration (includes coverage for all contraceptive devices including the associated office visit) 100%, no deductible
Durable medical equipment, orthotics, consumable medical suppliesi 80%
Prosthetic appliances (including external breast prostheses, wigs) 80%
Breast pumps and supplies (electronic breast pump limited to one per 36 months) 100%, no deductible
Lactation consultation 100%, first 6 visits; no deductible/copay; then 80% after deductible
Infertility treatment (limited to diagnostic testing and corrective surgery) 80%
Sterilization (female tubal ligation) 100% covered, no deductible/copay; includes ancillary services
Sterilization (male vasectomy) 80%
Outpatient rehabilitation (physical/speech/occupational therapy) and cardiac rehabilitation (A combined maximum of 60 visits per plan year applies to physical, speech and occupational therapy, with no medical review required. Additional visits are not covered.)j 80%
Coverage for autism spectrum disorders, including physical therapy/occupational therapy/speech therapy (PT/OT/ST visit limit applies) 80%
Applied Behavioral Analysis (ABA) (requires precertification) 80%
TMJ (medical treatment for TMJ covered; TMJ-related dental services and orthodontic appliances not covered) 80%

a Benefits are subject to recognized charge limits.
b You may need to pay the full amount and submit a claim for reimbursement to Aetna.
c Precertification penalties and amounts above recognized charges do not apply to the plan year deductible or out-of-pocket maximum. Office visit copays and urgent care facility copays do not apply to the plan year deductible; however, they do apply to the out-of-pocket maximum. Prescription drug expenses apply to the plan year deductible and out-of-pocket maximum.
d Unless otherwise noted, benefits paid at 80% or 60% are paid after the plan year deductible has been met.
e The office visit copay covers lab and X-ray charges performed in a doctor's office and billed as part of the visit. When these services are not performed at the time of the office visit, performed at another facility or performed by an entity other than the doctor's office, you must first meet your deductible and then the expense, if covered, would be paid at 80%.
f Except for routine physicals, which are covered annually, preventive care benefits are subject to age restrictions/limitations as determined under guidelines established by Aetna. For additional information about covered preventive care benefits, contact Aetna Member Services at 1-866-436-2606.
g Includes all tests (e.g., lab work, X-rays) associated with the visit and all office-based procedures.
h Precertification required; benefits may be reduced or denied if precertification not obtained.
i Deductible waived for diabetic insulin pumps and tubing.
j Speech therapy is subject to medical review if one of the following circumstances exist: developmentally delayed due to an injury or sickness (other than a functional nervous disorder); diagnosis of chronic otitis media; or a congenital defect for which corrective surgery has been performed.

 

Publication date: April 2019

 

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