Provision

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					Aetna                                                                                       Retiree MIP Plan 1
                                                                      In-Network
Effective January 1, 2007                                       Aetna Open Choice PPO                     Out-of-Network
General
Medical Deductible (per person)                                                    $400 per calendar year
Medical Deductible (per family)                                                    $800 per calendar year
Out-of-pocket limits (excludes co-payments and out-of-pocket expenses for mental health and substance abuse
office visits and dental services)
Medical out-of-pocket limit per person                                            $3,250 per calendar year
Medical out-of-pocket limits per family                                           $6,500 per calendar year
Pharmacy out-of-pocket limit per person                          $1,250 per calendar year                 Apply to Medical
                                                                                                      out-of-pocket limit above
Pharmacy out-of-pocket limits per family                         $2,500 per calendar year                 Apply to Medical
                                                                                                      out-of-pocket limit above
Office visits
Routine physical or OB/GYN, Pap smear, well baby visit
                                                                  100% after $15 copay
Illness                                                                                                 80% after deductible
Immunizations                                                     100% if no office visit
Mammogram, routine PSA test                                               100%                          80% after deductible
Emergency room related
Emergency Room                                                90% after deductible (80% after deductible if non-emergency use)
Ambulance Services                                                 90% after deductible                 90% after deductible
Inpatient
Hospital costs including anesthesia
Surgery (physician)                                                                 90% after deductible
Hospice
Outpatient
Facility charges, anesthesia, surgery (physician)                                   90% after deductible
Hospice
Laboratory and X-rays
All services                                                       90% after deductible                 80% after deductible
Chemotherapy and Radiation Therapy
Chemotherapy and Radiation Therapy                                         100% - in office/facility administration
                                                              Does not include oral medications purchased through pharmacy
Maternity
Obstetrics: Single fee/delivery charge incl. Office visits         90% after deductible                 80% after deductible
Obstetrics: Office visits billed separately from single fee       100% after $15 copay                  80% after deductible
Infertility                                                        90% after deductible                 80% after deductible
Infertility Lifetime Limits                                    Artificial Insemination or Ovulation Induction: 6 attempts each.
                                                                               Advanced Reproduction Therapy:
                                                               $50,000 for medical services and prescription drugs combined
Mental Health and Substance Abuse
Inpatient hospitalization                                          90% after deductible                 90% after deductible
Outpatient facility                                                90% after deductible                 90% after deductible
Office visit                                                      100% after $15 copay                  80% after deductible
Annual limits                                                                50 office visits per calendar year
                                                                       combined Mental Health and Substance Abuse
Lifetime maximum                                                      90 days hospitalization (Substance Abuse only)
Nursing and Home Health Care
Skilled Nursing Facility
(e.g., Rehabilitation Center)
Maximum 60 days per condition per calendar year                    90% after deductible                 80% after deductible
Visiting Nurse
Maximum 120 days per condition per calendar




                                                                                          M\TeamInsurance\PlanDesign2007\Retiree Plan 1
Aetna                                                                                      Retiree MIP Plan 1
Private Duty Nursing



                                                                     In-Network
Effective January 1, 2007                                      Aetna Open Choice PPO                       Out-of-Network
Short Term Rehabilitation
Physical, occupational or speech therapy –
Restorative service after illness or accident
Physical, occupational or speech therapy –
For diagnosis of Development Delay a maximum 60                 100% after $15 co-pay                    80% after deductible
visits PT, OT, ST combined, per year, per child
Chiropractor (30 visit limit per year)
Acupuncture (30 visit limit per year)
Durable Medical Equipment
Durable Medical Equipment Rentals.
                                                                  90% after deductible                   80% after deductible
Purchases only if approved by Insurance Administrator.
Vision Care
Routine eye exams (one per calendar year) including
                                                                 100% after $15 copay                    80% after deductible
refraction
Frames, lenses, contacts                                                 Up to $100 per year, claim form required
Hearing Aids
Hearing Aids                                                Up to $2,000 per person, every five plan years, claim form required
Prescription drugs                                                   PharmaCare                                All other
Pharmacy out-of-pocket limits per person                       $1,250 per calendar year                     Apply to medical
Pharmacy out-of-pocket limits per family                       $2,500 per calendar year                out-of-pocket limits above
Annual deductible, per person                                            $100
Generic (retail or mail order)                                    100%, no deductible               Generics and Brand Names
Brand-name Formulary                                           80%, subject to deductible           80% after medical deductible


Brand-name Non-Formulary                                       70%, subject to deductible
Brand-name Mail Order                                       Co pay based on Formulary or                    Not applicable
                                                            Non Formulary - No deductible
Specialty Pharmacy                                             80%, subject to deductible           80% after medical deductible
Dental                                                            Aetna Dental PPO                             All other
Deductibles
Deductible (per person)                                                                      $250
Deductible (per family)                                                                      $500
Maximum Coverage
Dental Expenses per person                                                       $3,200 per calendar year
Periodontal-Surgical expenses                                                               No limit
Orthodontia                                                                  $2,400 per insured (lifetime limit)
Preventative Care
Two routine oral exams per year including cleaning
                                                                  100%, no deductible                     80%, no deductible
Diagnostic X-rays, fluoride treatment, sealants
Minor Restorative and other dentally necessary services as determined by administrator, eg, third cleaning
Periodontics, endodontics, fillings, extractions                                   80% after deductible
Major Restorative
Crowns, inlays, bridges, dentures, implant devices                                 80% after deductible
Special Periodontics and Oral Surgery
Gingivectomy, gingioplasty, alveoplasty, vestibuloplasty,
                                                                 90% after deductible                    80% after deductible
osseous surgery, implant surgery, oral surgery
Orthodontics
Orthodontics                                                                       80% after deductible




                                                                                         M\TeamInsurance\PlanDesign2007\Retiree Plan 1

				
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posted:9/29/2011
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