Open Choice PPO

Summary of Benefits

BENEFITS	IN-NETWORK	OUT-OF-NETWORK
Annual Deductible	$0	$125 Individual $375 Family
Co-Insurance (% at which the plan pays benefits)	100% except where noted	100% Hospital;80% all other, except where noted
Annual Out-of-Pocket Maximum	n/a	$1000 Individual $3000 Family (network and prescription drug co-pays do not count towards the out-of-pocket limit
Lifetime Maximum	Unlimited Benefits
Claim Submission	Provider files claims	You file claims
HOSPITAL SERVICES AND RELATED CARE
Coverage In-patient Out-patient	100%	100%
MANDATORY PRE-REGISTRATION (1-800-333-4432) Applies to in-patient hospital, skilled nursing facility, home health care, hospice care, and private duty nursing care	Provider responsible	You or provider responsible
(For emergency admission, call within 48 hours or next business day if admitted on weekend)
Hospital Emergency Room Based on symptoms, i.e. constituting a perceived life threatening situation	100% including physician's charges after $35 co-pay (waived if admitted within 24 hours)	100% including physician's charges after $35 co-pay (waived if admitted within 24 hours)
Hospital Emergency Room For non-emergency care (examples of conditions: skin rash, ear ache, bronchitis, etc.)	80%	80% after deductible
Ambulance [There are no network providers for these services at the present time.]	100%
Skilled Nursing Facility	100% Up to 365 days per year for restorative care as determined by medical necessity.
Private Duty Nursing (in-home only)	100% subject to yearly limits of $5,000 and 70 "shifts" as well as $10,000 lifetime. Must be determined to be medically necessary and supported by a doctor's prescription/medical report. Precertification is strongly recommended.
Home Health Care Up to 200 visits per year	100% Must be determined to be medically necessary and supported by a doctor's prescription/medical report. Pre-certification is strongly recommended.
Hospice (210 days) Plus 5 days bereavement counselling	100%
PHYSICIAN SERVICES (excluding mental health and substance abuse treatment)
Office Visits For treatment of illness or injury (non-surgical)	100% after $15 co-pay	80% after deductible
Maternity (includes voluntary sterilization and voluntary abortion, see Family Planning)	100% after $15 co-pay	80% after deductible
Physician In-Hospital Services	100%	80% after deductible
Other In-Hospital Physician Services(e.g. attending/independent physician who does not bill through hospital)	100%	80% after deductible
Surgery (in hospital or office)	100%	80% after deductible
Second Surgical Opinion	100% after $15 co-pay	100% after deductible
Anaesthesia	100% (if participating hospital)	80% after deductible
Allergy Testing and Treatment (given by a physician)	100% after $15 co-pay	80% after deductible
Allergy Injections (not given by a physician)	100%	80% after deductible
PREVENTIVE CARE
Routine Physicals and Immunizations Children age 19+ and adults: one routine exam every 24 months Age 65+: one routine exam every 12 months	100% after $15 co-payment	80% after deductible
Well-child Care and ImmunizationsWell-child care to age 7: 6 visits per year age 0 to 1 year 2 visits per year age 1 to 2 years 1 visit per year age 2 to 7 years One visit every 24 months from age 7 to 19	100%
Routine Ob/Gyn Exam One routine exam per calendar year including one Pap smear	100% after $15 co-pay	80% after deductible
Family Planning Office visits including tests and counselling Surgical sterilization procedures for vasectomy/tubal ligation (excludes reversals)	100% after $15 co-pay 100%	80% after deductible 80%(deductible waived)
Infertility Treatment Office visits including testing and counselling Limited to procedures for correction of infertility including artificial insemination (but excluding in-vitro fertilization, G.I.F.T., Z.I.F.T., etc.) Limited to 6 treatments per lifetime	100% after $15 co-pay   100%	80% after deductible
Routine Mammogram (no age limit)	100%	80% after deductible 100% if performed on an in-patient basis or in the out-patient department of a hospital
Annual Urological exam by Urologist	100%	80% after deductible
MENTAL HEALTH AND ALCOHOL/DRUG ABUSE SERVICES
MENTAL HEALTH IN-PATIENT SERVICES (1-800-424-1601) In-patient Coverage [The benefit maximum is for network and non-network services combined.]	100% Maximum benefit of 90 days per calendar year	100% after deductible Maximum benefit of 90 days per calendar year
These services are provided by Aetna Behavioral Health. Pre-registration of in-patient confinements is required. For in-network services, the network provider is responsible for pre-registration. For non-network in-patient services, either the physician or the participant must pre-register the confinement.
Out-patient Coverage [The benefit maximum is for network and non-network services combined.]	100% Up to 50 visits per calendar year	80% after deductible Up to 50 visits per calendar year
Crisis Intervention	100% Up to 3 visits per calendar year	80% after deductible Up to 3 visits per calendar year
ALCOHOL/DRUG ABUSE In-patient Coverage[The benefit maximum is for network and non-network services combined.]	100% Up to 60 days per calendar year 120 days a lifetime	100% after deductible Up to 60 days per calendar year 120 days a lifetime
Out-patient Coverage[The benefit maximum is for network and non-network services combined.]	100% Up to 60 visits per calendar year	80% after deductible Up to 60 visits per calendar year
PRESCRIPTION DRUG BENEFITS
Aetna Retail Rx (1-800-784-3991) Aetna Global Retail Rx (1-800-231-7729) Retail means regular 30-day supply	20% co-pay with minimum of $5 or cost of Rx and up to a maximum of $20 per prescription	Within US: 60% after deductible Outside US: 80% after deductible. The co-insurance will not count towards $1,000/$3,000 out-of-pocket limit
Aetna Mail Order Rx (1-866-612-3862) Aetna Global Retail Rx (1-800-231-7729) Mail order means 90-days supply	100% after $15 co-pay for up to a 90-day supplyfrom participating mail order vendor
Prescriptions for Mail Order Programme - when a brand-name drug is dispensed and an equivalent generic is available, the member will pay $15 co-pay PLUS the difference in cost between the generic and the brand-name drug UNLESS the doctor specifies the brand-name drug by writing "DAW" or "Dispense as Written" on the prescription. In that event, you pay the normal $15 co-pay only.
VISION AND HEARING CARE
Eye Exam (once every 12 months)	100% after $15 co-pay	80% after deductible
Optical Lenses (including contact lenses once every 12 months)	80%, deductible does not apply;$100 maximum for any two lenses and frames purchased in a 12-month period
Vision One Programme(1-800-793-8616) Discount information for laser surgery(1-800-422-6600)	Save up to 65% on frames, up to 50% on lenses, and about 20% on contact lenses at participating Cole Vision Centers. Discounts available for laser surgery.
Hearing Exam Evaluation and Audiometric Exam	100% after $15 co-pay (one exam every three years; exam must be performed by otolaryngologist or state certified audiologist)	80% after deductible (one exam, limited to $100 reimbursement every three years; exam must be performed by otolaryngologist or state certified audiologist)
Hearing Device[There are no network providers for these services at the present time.]	80%, deductible does not apply; $750 maximum benefit, one hearing aid per ear every three years
OTHER HEALTH CARE
Short-term Rehabilitation Physical and Occupational Therapy	100%	80% after deductible
Laboratory Tests, Diagnostic X-Rays	100%	80% after deductible
Speech Therapy	80%, deductible does not apply(where services are rendered by a participating provider, 100% reimbursement applies after $15 co-pay)
Out-patient Diabetic Self-Management Education Programme	80%, deductible does not apply [If services are rendered in a hospital, 100% reimbursement applies with no co-pay. If rendered in a network doctor's office, 100% reimbursement with $15 co-pay applies]
Durable Medical Equipment	80%, deductible does not apply [If services are rendered by a network provider or within a hospital setting, 100% reimbursement applies with no co-pay]
Acupuncture (for chronic pain treatment only; services must be rendered by a medical doctor or licensed acupuncturist)	100% after $15 co-pay up to a maximum benefit of $1,000/year	80% after deductible up to a maximum benefit of $1,000/year
	[Network and non-network benefits are combined for a maximum of $1,000 per calendar year]
Chiropractic Care	100% after $15 co-pay up to a maximum benefit of $1,000/year	80% after deductible up to a maximum benefit of $1,000/year
	[Network and non-network benefits are combined for a maximum of $1,000 per calendar year]