|
"Bold" print
identifies plan changes effective 1/1/2003
|
|
Plan
Name
|
Community
Choice 2000 Referred Care
QPOS
|
Community
Choice 2000 Self-Referred Care
QPOS
|
|
Web Site
|
www.aetnaushc.com
|
www.aetnaushc.com
|
|
Member
Service Number
|
1-888-403-0400
|
1-888-403-0400
|
|
Individual
Lifetime Maximum Benefits
|
None
|
$1
Million
|
|
Annual
Deductible
|
|
|
|
Individual
|
None
|
None
|
|
Family
|
None
|
None
|
|
Coinsurance
|
None
|
25%
|
|
Annual
Out-of-Pocket Maximum
|
|
|
|
Individual
|
None
|
$2,000
|
|
Family
|
None
|
$4,000
|
|
Inpatient
Hospital
|
100%
|
75% |
|
Physician
Services: PCP Office Visit
|
$10
copay
|
75%
|
|
Emergency
Care: In-area Hospital
|
100%
- $25 copay applies/ Waived if admitted. 75% for non-emergency
care
|
100%
- $25 copay applies. Waived if admitted. 75% for non-emergency
care |
|
Outpatient
X-Ray and Lab
|
100%
|
75% |
|
Durable
Medical Equipment
|
100%
|
75%
|
|
Retail
Prescription Coverage
|
|
|
|
Generic
|
20%
|
20%
|
|
Brand Name
|
30%
if generic unavailable; 50% if Generic available and medically
necessary
|
30%
if generic unavailable; 50% if Generic available and medically
necessary |
|
Mail-Order
Prescription Coverage
|
|
|
|
Generic
|
10%
Generic; 20% Brand if Generic unavailable; 40% if Generic available
and medically necessary |
10%
Generic; 20% Brand if Generic unavailable; 40% if Generic available
and medically necessary |
|
Brand Name
|
See
Above |
See
Above
|
|
Diabetic
Benefits
|
|
|
|
Insulin
|
Covered
Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit |
|
Chem. Strips/Lancets
|
Covered
Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit
|
|
Home Health Care
|
100%
|
75%
- limited to 100 visits per calendar year
|
|
Mental
Health
|
|
|
|
Inpatient
|
100%
up to 30 days per calendar year
|
75%
up to 30 days per calendar year
|
|
Outpatient
|
100%
after $10 copay limited to 20 visits per calendar year
|
75%
limited to 20 visits per calendar year
|
|
Substance Abuse
|
|
|
|
Inpatient
|
100% - 30 days per calendar year; 90 days lifetime
|
75% - 30 days per calendar year; 90 days lifetime
|
|
Outpatient
|
100% after $10 copay - 30 visits per calendar year; 120 visits per
lifetime
|
75% - 30 visits per calendar year; 120 visits per lifetime
|
|
Vision
Care
|
|
|
|
Routine Eye Exam |
VisionOne
Discount Program
|
Not Covered
|
|
Eyeglasses and Contact Lenses
|
VisionOne
Discount Program
|
Not Covered
|
|
Hearing
Care |
|
|
|
Exam |
Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
|
Not Covered
|
|
Hearing Aids |
Provided
by National Ear Care Plan
(NECP)
- 1-800-999-1458
|
Not Covered
|
|
Dental
Care |
|
|
|
Basic Services |
Not Covered
|
Not Covered
|
|
Major Services |
|
|
|
Preventive Services |
Not Covered
|
Not Covered
|
|
Wellness
Benefits |
$10
Copay
|
Not Covered
|