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"Bold" print
identifies plan changes effective 1/1/2003
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Plan
Name
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Aetna
U.S. Healthcare - Southeast Pennsylvania
HMO
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Community
Choice 2000 Referred Care
QPOS
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Community
Choice 2000 Self-Referred Care
QPOS
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Web Site
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www.aetnaushc.com
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www.aetnaushc.com
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www.aetnaushc.com
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Member
Service Number
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1-800-323-9930 US00732
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1-888-403-0400
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1-888-403-0400
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Individual
Lifetime Maximum Benefits
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None
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None
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$1
Million
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Annual
Deductible
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Individual
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None
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None
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None
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Family
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None
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None
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None
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Coinsurance
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None
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None
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25%
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Annual
Out-of-Pocket Maximum
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Individual
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None
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None
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$2,000
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Family
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None
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None
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$4,000
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Inpatient
Hospital
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100%
covered
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100%
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75% |
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Physician
Services: PCP Office Visit
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$15 copay
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$10
copay
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75%
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Emergency
Care: In-area Hospital
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$35
copay
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100%
- $25 copay applies/ Waived if admitted. 75% for non-emergency
care
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100%
- $25 copay applies. Waived if admitted. 75% for non-emergency
care |
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Outpatient
X-Ray and Lab
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$15
copay
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100%
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75% |
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Durable
Medical Equipment
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100%
covered
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100%
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75%
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Retail
Prescription Coverage
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Generic
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$10
copay
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15%
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15%
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Brand Name
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$15
copay for Preferred Brand Names;
$30
copay for 30-day supply of Non-Preferred Brand Names
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25%
if generic unavailable; 30% if Generic available and medically
necessary
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25%
if generic unavailable; 30% if Generic available and medically
necessary |
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Mail-Order
Prescription Coverage
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Generic
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$20
copay for 90-day supply
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10%
Generic; 20% Brand if Generic unavailable; 25% if Generic available
and medically necessary |
10%
Generic; 20% Brand if Generic unavailable; 25% if Generic available
and medically necessary
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Brand Name
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$30
copay for 90-day supply of Preferred Bran Names;
$60
copay for 90-supply of Non-Preferred Brand Names
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See
Above |
See
Above
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Diabetic
Benefits
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Insulin
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100%
covered
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Covered
Under Pharmacy Benefit
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Covered
Under Pharmacy Benefit |
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Chem. Strips/Lancets
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100%
covered
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Covered
Under Pharmacy Benefit
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Covered
Under Pharmacy Benefit
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Home Health Care
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100%
covered
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100%
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75%
- limited to 100 visits per calendar year
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Mental
Health
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Inpatient
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100%
covered, limit 35 days per calendar year
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100%
up to 30 days per calendar year
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75%
up to 30 days per calendar year
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Outpatient
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$25
copay, limit 20 visits per calendar year
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100%
after $10 copay limited to 20 visits per calendar year
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75%
limited to 20 visits per calendar year
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Substance Abuse
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Inpatient
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100%
covered, limit 30 days per calendar year
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100% - 30 days per calendar year; 90 days lifetime
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75% - 30 days per calendar year; 90 days lifetime
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Outpatient
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$15
copay , limit 60 visits
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100% after $10 copay - 30 visits per calendar year; 120 visits per
lifetime
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75% - 30 visits per calendar year; 120 visits per lifetime
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Vision
Care
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Routine Eye Exam |
$15
copay
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VisionOne
Discount Program
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Not Covered
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Eyeglasses and Contact Lenses
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Up
to $70 reimbursement every 24 months
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VisionOne
Discount Program
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Not Covered
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Hearing
Care |
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Exam |
$15
copay
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Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
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Not Covered
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Hearing Aids |
Not Covered
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Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
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Not Covered
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Dental
Care |
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Basic Services |
Not Covered
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Not Covered
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Not Covered
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Major Services |
Not Covered
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Not
Covered
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Not
Covered
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Preventive Services |
$5
pediatric copay
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Not Covered
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Not Covered
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Wellness
Benefits |
Yes
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$10
Copay
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Not Covered
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