Health+Savings PPO Option summary chart

The Health+Savings PPO Option is available only if you live in an area where the Aetna Choice POS II network is available; otherwise, the Out-of-Area Option is available to you.

If you participate in an Out-of-Area Option, see the Out-of-Area (OOA) Options (HealthPlus and Standard) summary chart or the Health+Savings Out-of-Area (OOA) Option chart.


 
Health+Savings PPO Option
2021/2022 Plan Year
Network  Out-of-Networka,b
General information  
Plan year deductiblec,d

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 $3,000 if you have You Only coverage; $6,000 if you have You + Spouse, You + Child(ren) or You + Family coverage
Plan year out-of-pocket maximumc,d

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 $8,000 if you have You Only coverage; $16,000 if you have You + Spouse, You + Child(ren) or You + Family coverage
Lifetime maximum benefit None 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
Certain generic preventive prescriptions 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 – non-preventive After medical deductible is met, 100% after $5 copay (deductible and copay waived for certain generic preventive)
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 – non-preventive After medical deductible is met, 100% after $12 copay (deductible and copay waived for certain generic preventive)
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 PPO Option pays
Doctor visits (other than preventive care)e
Primary care office visit 100% after $20 copay, after deductiblef
Note: surgery is covered at 80% after deductible
60%
Specialist office visit 100% after $30 copay, after deductiblef
Note: surgery is covered at 80% after deductible
60%
Behavioral health office visit 100% after $20 copay, after deductiblef 60%
Maternity services 100%, no deductible/copay (prenatal); 80% after deductible (post-natal) 60%
Lab and X-ray 80%f 60%f
Preventive caree,h
Routine physicals 100%, no copay, no deductible 60%
Annual well-woman exams 100%, no copay, no deductible 60%
Mammograms (routine) 100%, no copay, no deductible 60%
Gestational diabetes screening 100%, no copay, no deductible 60%
Prostate Specific Antigen (PSA) tests (routine) 100%, no copay, no deductible 60%
Colorectal screenings (routine) 100%, no copay, no deductible 60%
Well-child care (routine) 100%, no copay, no deductible 60%
Emergency servicese
Emergency room (applies to facility charges only)i 80% after $150 copay, after deductible 80% after $150 copay, after deductible
Ambulance 80% 80%
Urgent care facility (applies to facility charges only) 100% after $30 copay, after deductible 60%
Outpatient services (services provided other than in a doctor's office)e  
Outpatient surgery facility 80% 60%g
Hospital outpatient services 80% 60%g
Doctor/surgeon and related professional fees 80% 60%
Behavioral health outpatient treatment (other than office visit) 80% 60%j
Lab 80%m 60%
X-ray 80%m 60%g
Radiation therapy/chemotherapy 80%m 60%
Inpatient hospital servicese
Room and board (semi-private room) 80% 60%g,j
Inpatient behavioral health stay, including residential treatment and partial hospitalization 80% 60%g,j
Doctor hospital visits 80% 60%
Lab and X-ray 80% 60%g
Anesthesia 80% 60%
Alternatives to inpatient hospital caree
Skilled nursing facility (up to 60 days/plan year)k 80% 60%g,j
Home health care (limited to 120 visits/plan year; limit does not apply to behavioral health claims)k 80% 60%j
Hospice care 80% 60%g,j
Outpatient private duty nursing (up to 70 shifts/plan year)k 80% 60%j
Other covered servicese
Chiropractic care (including lab/X-ray provided by a chiropractor); up to 20 visits/plan yeark 80% 60%
Contraceptive administration (includes coverage for all contraceptive devices including the associated office visit) 100%, no deductible 60%
Durable medical equipment, orthotics, consumable medical suppliesl 80% 60%
Prosthetic appliances (including external breast prostheses, wigs) 80% 60%
Breast pumps and supplies (electronic breast pump limited to one per pregnancy) 100%, no deductible 60%
Lactation consultation 100%, no deductible/copay for first 6 visits; then deductible and primary care/specialist copay applies (deductible and coinsurance apply if not part of office visit) 60%
Infertility treatment (limited to diagnostic testing and corrective surgery) 80% 60%
Infertility treatment through Progyny (including IVF, IUI and fertility preservation; limited to employees and covered spouses/domestic partners) 80%, limited to 3 "Smart Cycles" through Progyny network n/a
Sterilization (female tubal ligation) 100% covered, no deductible/copay; includes ancillary services 60%
Sterilization (male vasectomy) 80% 60%
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 except for behavioral health claims, in which case the visit limit does not apply.)n
80% 60%
Coverage for autism spectrum disorders, including physical therapy/occupational therapy/speech therapy (PT/OT/ST visit limit applies) 80% 60%
Applied Behavioral Analysis (ABA) (requires precertification) 80% 60%
TMJ (medical treatment for TMJ covered; TMJ-related dental services and orthodontic appliances not covered) 80% 60%

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 Covered network expenses do not apply to the plan year out-of-network deductible or out-of-pocket maximum, and covered out-of-network expenses do not apply to the plan year network deductible or out-of-pocket maximum.

d Precertification penalties and amounts above recognized charges do not apply to the plan year deductible or out-of-pocket maximum. Office visit copays and emergency room/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.
e Unless otherwise noted, benefits paid at 80% or 60% are paid after the plan year deductible has been met.
f 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 network facility or performed by a network entity other than the doctor's office, you must first meet your deductible and then the expense, if covered, would be paid at 80%.

g For facility charges and non-emergency admissions, reimbursement is limited to 60%, with a maximum allowed amount of 1.5 times the Medicare Fee Schedule for that area.
h For additional information about covered preventive care benefits, see the Preventive care section of this SPD or contact Aetna Member Services at 1-866-436-2606.

i Non-facility charges for emergency services incurred in the emergency room are paid at applicable network levels.

j Precertification required; benefits may be reduced or denied if precertification not obtained.

k The visit/plan year limit applies to total of both network and out-of-network visits.

l Deductible waived for diabetic insulin pumps and tubing.
m The following in-network services require precertification: cardiac imaging (including non-urgent outpatient diagnostic heart catheterizations and echo stress tests); cardiac rhythm implantable devices; sleep studies; high-tech radiology (e.g., MRI/MRA, CT scans, PET scans and nuclear imaging).
n 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 2021

 

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