SAP America
Effective Date: 01-01-
Aetna Choice™ POS ll -
PLAN DESIGN & BENEFITS
ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE
Deductible (per calendar year) $300 Individual $600
$600 Family $1,200
All covered expenses, excluding prescription drugs, accumulate toward both the preferred and non-preferred Deductible.
Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of
calendar year.
Member Coinsurance 85% 65%
Applies to all expenses unless otherwise stated.
Payment Limit (per calendar year) $2,500 Individual $5,000
$5,000 Family $10,000
All covered expenses, excluding prescription drugs, accumulate toward both the preferred and non-preferred Payment Lim
Certain member cost sharing elements may not apply toward the Payment Limit.
Only those out-of-pocket expenses resulting from the application of coinsurance percentage (except any deductibles, copa
and penalty amounts) may be used to satisfy the Payment Limit.
Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remain
of the calendar year.
Unlimited except where otherwise Unlimited except where otherwise
Lifetime Maximum indicated. indicated.
Primary Care Physician Selection Optional Not applicable
Certification Requirements -
Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care.
Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care
Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $300
occurrence.
Referral Requirement None None
PREVENTIVE CARE PREFERRED CARE NON-PREFERRED CARE
Routine Adult Physical Exams/ Covered 100%; deductible waived 65% deductible waived
Immunizations
1 exam per calendar year for members age 18 to age 65; 1 exam per calendar year for adults age 65 and older.
Routine Well Child Exams/Immunizations Covered 100%; deductible waived 65% deductible waived
7 exams in the first 12 months of life, 3 exams in the 13th-24th months of life, 3 exams in the 25th-36 months of life, 1 exa
per 12 months thereafter to age 18.
Routine Gynecological Care Exams Covered 100%; deductible waived 65% deductible waived
1 routine exam per calendar year
Includes routine tests and related lab fees
Routine Mammograms Covered 100%; deductible waived 65% deductible waived
1 test per calendar year
For covered females age 35 and over.
Routine Digital Rectal Exam / Prostate- Covered 100%; deductible waived 65% deductible waived
specific Antigen Test
1 routine exam per calendar year
For covered males age 40 and over.
Colorectal Cancer Screening Covered 100%; deductible waived 65% deductible waived
For all members age 50 and over.
Routine Eye Exams Covered 100%; deductible waived 65% deductible waived
1 routine exam per calendar year
Routine Hearing Screening Covered 100%; deductible waived 65% deductible waived
1 routine exam every two calendar years
PHYSICIAN SERVICES PREFERRED CARE NON-PREFERRED CARE
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SAP America
Effective Date: 01-01-
Aetna Choice™ POS ll -
PLAN DESIGN & BENEFITS
ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
Office Visits to PCP Covered 100% after $20 office visit 65% after deductible
copay; deductible waived
Includes services of an internist, general physician, family practitioner or pediatrician.
Specialist Office Visits Covered 100% after $35 office visit 65% after deductible
copay; deductible waived
Allergy Testing Covered as either PCP or specialist 65% after deductible
office visit; deductible waived
Allergy Injections (Copay waived when an Covered as either PCP or specialist 65% after deductible
office visit charge is not made) office visit after deductible
DIAGNOSTIC PROCEDURES PREFERRED CARE NON-PREFERRED CARE
Diagnostic Laboratory and X-ray 85% after deductible 65% after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable
physician's office visit member cost sharing
EMERGENCY MEDICAL CARE PREFERRED CARE NON-PREFERRED CARE
Urgent Care Provider Covered 100% after $35 office visit 65% after deductible
(benefit availability may vary by location) copay; deductible waived
Non-Urgent Use of Urgent Care Provider Not Covered Not Covered
Emergency Room Covered 100% after $100 copay; Covered 100% after $100 copay;
copay waived if admitted to the hospital deductible waived deductible waived
Non-Emergency care in an Emergency 65% after deductible 65% after deductible
Room
Ambulance 85% after deductible 65% after deductible
HOSPITAL CARE PREFERRED CARE NON-PREFERRED CARE
Inpatient Coverage 85% after $250 per confinement 65% after $400 per confinement
copay after deductible deductible after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Inpatient Maternity Coverage 85% after $250 per confinement 65% after $400 per confinement
copay after deductible deductible after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Outpatient Surgery 85% after deductible 65% after deductible
Outpatient Hospital Expenses (excluding 85% after deductible 65% after deductible
surgery)
The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit
MENTAL HEALTH SERVICES PREFERRED CARE NON-PREFERRED CARE
Inpatient 85% after $250 per confinement 65% after $400 per confinement
copay after deductible deductible after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Outpatient Covered 100% after $35 office visit 65% after deductible
copay; deductible waived
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
ALCOHOL/DRUG ABUSE SERVICES PREFERRED CARE NON-PREFERRED CARE
Inpatient 85% after $250 per confinement 65% after $400 per confinement
copay after deductible deductible after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Outpatient Covered 100% after $35 office visit 65% after deductible
copay; deductible waived
The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit
OTHER SERVICES PREFERRED CARE NON-PREFERRED CARE
Convalescent Facility 85% after deductible 65% after deductible
Limited to 60 days per calendar year.
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SAP America
Effective Date: 01-01-
Aetna Choice™ POS ll -
PLAN DESIGN & BENEFITS
ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
The member cost sharing applies to all covered benefits incurring during a member's inpatient stay
Home Health Care 85% after deductible 65% after deductible
Limited to 120 visits per calendar year. Includes Private Duty Nursing limited to 70 eight hour shifts per calendar year.
Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit.
Hospice Care - Inpatient 85% after deductible 65% after deductible
Limited to 30 days per lifetime.
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay
Hospice Care - Outpatient 85% after deductible 65% after deductible
The member cost sharing applies to all covered benefits incurred during a member's outpatient visit
Outpatient Short-Term Rehabilitation $20 copay after deductible 65% after deductible
Include Speech, Physical, and Occupational Therapy, limited to 100 combined visits per calendar year.
Spinal Manipulation Therapy $35 copay after deductible 65% after deductible
Limited to $1,500 per calendar year
Durable Medical Equipment 85% after deductible 65% after deductible
Diabetic Supplies 85% after deductible 65% after deductible
Contraceptive drugs and devices not 85% (payable as any other covered 65% (payable as any other covere
obtainable at a pharmacy (includes coverage expense) after deductible expense) after deductible
for contraceptive visits)
Transplants 85% after $250 per confinement 65% Non-Preferred coverage is
copay Preferred coverage is provided provided at a Non-IOE facility; afte
at an IOE contracted facility only; after deductible
deductible
Bariatric 85% after $250 per confinement 65% after $400 per confinement
copay after deductible deductible after deductible
The member cost sharing applies to all covered benefits incurred during a member's inpatient stay.
Mouth, Jaws and Teeth 85% after deductible 65% after deductible
(oral surgery procedures, whether medical or
dental in nature) excludes appliances
Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan; after
deductible
FAMILY PLANNING PREFERRED CARE NON-PREFERRED CARE
Infertility Treatment Member cost sharing is based on the Member cost sharing is based on
type of service performed and the type of service performed and the
place of service where it is rendered; place of service where it is render
after deductible after deductible
Diagnosis and treatment of the underlying medical condition.
Comprehensive Infertility Services 85%; does not apply towards the 65% after deductible
overall Payment Limit; after deductible
Coverage includes Artificial Insemination (limited to six courses of treatment per member's lifetime) and Ovulation Inductio
(limited to six courses of treatment per member's lifetime). Lifetime maximum applies to all procedures covered by any Ae
plan except where prohibited by law.
Advanced Reproductive Technology (ART) 85%; does not apply towards the 65% after deductible
overall Payment Limit; after deductible
ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIF
cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery.
Prepared: 11/10/2011 01:56 PM Page 3
SAP America
Effective Date: 01-01-
Aetna Choice™ POS ll -
PLAN DESIGN & BENEFITS
ADMINISTERED BY AETNA LIFE INSURANCE COMPANY
Limited to $15,000 in members lifetime. Maximum applies to all procedures covered by any Aetna plan except where
prohibited by law.
Voluntary Sterilization Member cost sharing is based on the Member cost sharing is based on
Including tubal ligation and vasectomy. type of service performed and the type of service performed and the
place of service where it is rendered; place of service where it is render
after deductible after deductible
PHARMACY PREFERRED CARE NON-PREFERRED CARE
Retail $10 copay for generic drugs; 10% Not Covered
coinsurance for formulary brand-
name drugs with a minimum
coinsurance of $25, maximum
coinsurance amount of $50, and 20%
coinsurance for non-formulary brand-
name drugs with a minimum
coinsurance amount of $45,
maximum coinsurance amount of $90
up to a 30 day supply at participating
pharmacies.
Mail Order $20 copay for generic drugs; 10% Not Covered
coinsurance for formulary brand-
name drugs with a minimum
coinsurance of $40, maximum
coinsurance amount of $80, and 20%
coinsurance for non-formulary brand-
name drugs with a minimum
coinsurance amount of $80,
maximum coinsurance amount of
$160 up to a 31-90 day supply at
participating pharmacies.
Pharmacy Managed Self Injectables (PMSI)
First prescription fill at any retail or mail order drug facility. Subsequent fills must be through Aetna Specialty Pharmacy®
Mandatory Generic (MG) - If the member or the physician requests brand when generic is available, the member pays th
applicable copay plus the difference between the generic price and the brand price.
Plan Includes: Performance Enhancing Medication, Diabetic supplies and contraceptive drugs and devices obtainable fr
a pharmacy.
Oral fertility drugs, Injectable fertility drugs (injectable, physician charges for injections are not covered under RX, medical
coverage may be limited) limited to $15,000 per lifetime.
GENERAL PROVISIONS
Dependents Eligibility Spouse, children from birth to age 26
This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their
documents to determine which health care services are covered and to what extent. The following is a partial list of servic
and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on s
mandates or the plan design or rider(s) purchased by your employer.
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SAP America
Effective Date: 01-01-
Aetna Choice™ to their
This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer POS ll -
PLAN DESIGN and to what
documents to determine which health care services are covered& BENEFITSextent. The following is a partial list of servic
ADMINISTERED BY your plan documents may COMPANY
and supplies that are generally not covered. However,AETNA LIFE INSURANCE contain exceptions to this list based on s
mandates or the plan design or rider(s) purchased by your employer.
All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charge
related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care;
Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations fo
travel or work.
Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Services for the
treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weig
control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and
supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or oth
equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid
Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions.
This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a
partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health
care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance
Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limita
relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent
contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LL
is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network compos
is subject to change without notice.
Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of
coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some o
the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatien
skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the
Member’s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the membe
utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Non-
prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollm
are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as o
print date, it is subject to change.
Plans are administered by Aetna Life Insurance Company.
Prepared: 11/10/2011 01:56 PM Page 5
SAP America, Inc
Effective Date: 01-01-2012
PPO 85
™
Aetna Choice POS ll - ASC
Y
N-PREFERRED CARE
Individual
Family
d non-preferred Deductible.
ductible for the remainder of the
Individual
Family
d non-preferred Payment Limit.
(except any deductibles, copays,
Payment Limit for the remainder
mited except where otherwise
ated.
applicable
benefits paid for that care.
dmissions, Home Health Care,
each type of expense is $300 per
e
N-PREFERRED CARE
deductible waived
s age 65 and older.
deductible waived
25th-36 months of life, 1 exam
deductible waived
deductible waived
deductible waived
deductible waived
deductible waived
deductible waived
N-PREFERRED CARE
Prepared: 11/10/2011 01:56 PM Page 6
SAP America, Inc
Effective Date: 01-01-2012
PPO 85
™
Aetna Choice POS ll - ASC
Y
after deductible
after deductible
after deductible
after deductible
N-PREFERRED CARE
after deductible
ered subject to the applicable
N-PREFERRED CARE
after deductible
Covered
ered 100% after $100 copay;
uctible waived
after deductible
after deductible
N-PREFERRED CARE
after $400 per confinement
uctible after deductible
t stay
after $400 per confinement
uctible after deductible
t stay
after deductible
after deductible
ent visit
N-PREFERRED CARE
after $400 per confinement
uctible after deductible
t stay
after deductible
nt visit
N-PREFERRED CARE
after $400 per confinement
uctible after deductible
t stay
after deductible
ent visit
N-PREFERRED CARE
after deductible
Prepared: 11/10/2011 01:56 PM Page 7
SAP America, Inc
Effective Date: 01-01-2012
PPO 85
™
Aetna Choice POS ll - ASC
Y
nt stay
after deductible
shifts per calendar year.
aide is one visit.
after deductible
t stay
after deductible
nt visit
after deductible
ndar year.
after deductible
after deductible
after deductible
(payable as any other covered
nse) after deductible
Non-Preferred coverage is
ded at a Non-IOE facility; after
uctible
after $400 per confinement
uctible after deductible
t stay.
after deductible
efit level of the plan; after
N-PREFERRED CARE
mber cost sharing is based on the
of service performed and the
e of service where it is rendered;
deductible
after deductible
etime) and Ovulation Induction
rocedures covered by any Aetna
after deductible
te intrafallopian transfer (GIFT),
ry.
Prepared: 11/10/2011 01:56 PM Page 8
SAP America, Inc
Effective Date: 01-01-2012
PPO 85
™
Aetna Choice POS ll - ASC
Y
Aetna plan except where
mber cost sharing is based on the
of service performed and the
e of service where it is rendered;
deductible
N-PREFERRED CARE
Covered
Covered
Aetna Specialty Pharmacy®
vailable, the member pays the
ugs and devices obtainable from
t covered under RX, medical
embers should refer to their plan
owing is a partial list of services
ceptions to this list based on state
Prepared: 11/10/2011 01:56 PM Page 9
SAP America, Inc
Effective Date: 01-01-2012
PPO 85
™
Aetna Choice to their ASC
embers should refer POS ll - plan
owing is a partial list of services
Y
ceptions to this list based on state
the plan documents; Charges
ast reduction; Custodial care;
earing aids; Immunizations for
upplies; Services for the
nd special duty nursing. Weight
ams, dietary regimens and
ise programs, exercise or other
eat obesity, including Morbid
itions.
al advice. It contains only a
Aetna does not provide health
ents (i.e. Group Insurance
edures, exclusions and limitation
nd vendors are independent
Aetna Rx Home Delivery, LLC,
and provider network composition
ication, or prior approval of
r denial of coverage. Some of
patient mental health, inpatient
ehabilitation). When the
rtification. When the member
quirements may vary. Non-
(received after open enrollment)
believed to be accurate as of the
Prepared: 11/10/2011 01:56 PM Page 10