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Deductibles, Networks, and Plan Summary
| Outside United States | Inside United States - In Network | Inside United States - Out of Network | |
|---|---|---|---|
Networks | All Medical Expenses (covered by the plan) are allowed. There is no network limitation. Aetna has over 168,000 medical provider relationships worldwide. | Aetna uses their own PPO network in the United States. "In-Network" refers to providers who are part of the PPO Network. | Aetna uses their own PPO network in the United States. "Out-of-Network" refers to providers who are not part of the PPO Network. |
| Annual Deductible for Medical Expenses | $0 | In-Network: $2000 single / $4000 family. Note that in-network and out-of-network are two separate deductibles, which cannot be combined. After deductible is met, covered medical expenses |
at |
the rates |
for In-Network |
providers. Often 100% is paid by the plan. See plan of benefits below for more information about care and type of medical expense. | Out-of-Network: $2000 single/ $4000 family. Note that in-network and out-of-network are two separate deductibles, which cannot be combined. After deductible is met, covered medical expenses are paid for at |
percentage rates |
for Out-of-Network |
providers. Often 80% is paid by the plan. See plan of benefits below for more information about care and type of medical expense. | |||
Prescription Drugs Vendor Relationships | Relationships vary by country. Prescription claims can be reimbursed online. | Aetna members may use Walgreens, Rite-aid, Safeway, CVS, Costco, and a few others. Mail order - Aetna RX home delivery is administered by CVS, but is branded as Aetna Home delivery. | Aetna members may use Walgreens, Rite-aid, Safeway, CVS, Costco, and a few others. Mail order - Aetna RX home delivery is administered by CVS, but is branded as Aetna Home delivery. |
|---|---|---|---|
| Prescription Drugs Costs | 100% covered prescription expenses. | In-Network: Generic drugs are $10 copay, formulary brand name drugs are $20 copay, and non formulary drugs are $40 copay, all per month supply. | Out-of-Network: All prescription drugs are 20% deductible waived. |
| Maternity Coverage for Plan Holder and/or Dependents | Covered as any other medical expense. | Covered as any other medical expense. | Covered as any other medical expense. |
| Diabetes Supplies | No charge. | In-Network: No charge. No annual maximum coverage. | Out-of-Network: 20% after deductible. No annual maximum coverage. |
| Vision | Routine eye exams are 100% covered. Vision care supplies are no charge up to $200 per 12 months. | In- Network: Routine eye exams are 100% covered, deductible waived, and vision care supplies are no charge up to $200 maximum coverage per 12 months. | Out-of-Network: US routine eye exams are 20% after deductible, and vision care supplies are no charge up to $200 maximum coverage per 12 months. |
| Employee Assistance Program | See Solomon Link for more information: | See Solomon Link for more information: | See Solomon Link for more information: |
| Global Emergency Assistance Program | Aetna's Global Emergency Assistance Program includes medical evacuation, repatriation coordination, companion travel and return of mortal remains/dependent children, along with medical assistance, with an unlimited calendar year maximum. Aetna partners with WorldAware, which includes security and political and natural disaster coverage. | NA | NA |
| Dental | Cost to Employee |
|---|---|
| Individual/Family Deductible Per Calendar Year | $100 single /$300 family |
| Dental Annual Maximum Coverage Per Person | $1500 |
Diagnostic and Preventative Care | Type A - No Charge |
| Basic Restorative | Type B - 20% after deductible |
| Major | Type C - 50% after deductible |
| Orthodontic | 50% for child only, with a $1500 lifetime maximum |
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