What the PPO Options pay

Network providers

Network providers have agreed to offer covered services at contracted rates. This means that the dollar amount you pay for your share of covered expenses is generally lower when you use a network provider. When you see a network provider:

  • Covered office visit expenses are covered at:
    • 100% after you pay a copay, with no deductible, by the HealthPlus PPO Option.
    • 80% after the deductible by the Standard PPO Option.
    • 100% after you pay a copay, and after you meet the deductible, by the Health+Savings PPO Option.
  • Under all PPO Options, in-network preventive care is covered at 100% with no copay and no deductible.
  • Emergency room facility charges are paid at:
    • 80% after a copay, with no deductible, by the HealthPlus and Standard PPO Options.
    • 80% after a copay, and after you meet the deductible, by the Health+Savings PPO Option.
  • Most other covered in-network services are paid at 80% of the contracted rate for other covered expenses after you meet the individual or family plan year deductible, and you pay the remaining portion of the charges (the coinsurance). 
  • Once you meet the plan year network out-of-pocket maximum, the PPO Options pay 100% of the contracted rate for covered expenses for the rest of the plan year.

See the applicable summary chart (HealthPlus and Standard PPOs or Health+Savings PPO) for more information.

If you are an active employee enrolled in the HealthPlus or Health+Savings Option, you can take advantage of the following reduced copays for services and prescriptions received at the Westlake Health and Wellness Center:

  • $10 copay for a primary care or specialist office visit
  • $10 copay for a physical therapy office visit
  • Home Delivery Program: 90-day supply of prescription drugs available onsite at Westlake Health and Wellness Center retail pharmacy, applicable copays apply ($12 copay for generic, $65 copay for formulary brand name, $125 copay for non-formulary brand name)
  • $0 copay for a vision exam

Remember, you may have to satisfy your medical plan deductible before these or any other copays apply.


Out-of-network providers

If you see an out-of-network provider, each PPO Option generally pays 60% of recognized charges for all covered expenses (except ambulance services, which are covered at 80% of recognized charges) after you meet the individual or family plan year deductible. You pay the remaining percentage (the coinsurance) and any costs above recognized charge limits. (See Recognized charge limits.) Note: Eligible claims incurred in an emergency room facility will be covered at the applicable in-network benefit level.

Once you meet the plan year out-of-network out-of-pocket maximum, each PPO Option pays 100% of recognized charges for most covered expenses for the rest of the plan year.

If you use a network hospital or doctor in Aetna's NAP for a covered expense, you may receive the advantage of contracted rates, however, if those providers are not in the Aetna Choice POS II Network, the charges will be considered out-of-network. (See National Advantage Program (NAP).)

 

Publication date: April 2019

 

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