Pennsylvania 4-6 - Retired Employees

"Bold" print identifies plan changes effective 1/1/2003
Plan Name	Community Choice 2000 Referred Care QPOS	Community Choice 2000 Self-Referred Care QPOS	Geisinger Health Plan PA
Web Site	www.aetnaushc.com	www.aetnaushc.com	www.thehealthplan.com
Member Service Number	1-888-403-0400	1-888-403-0400	1-800-447-4000 Pre-Enrollee No.1-800-631-1656
Individual Lifetime Maximum Benefits	None	$1 Million	None
Annual Deductible
Individual	None	None	None
Family	None	None	None
Coinsurance	None	25%	None
Annual Out-of-Pocket Maximum
Individual	None	$2,000	None
Family	None	$4,000	None
Inpatient Hospital	100%	75%	100% covered
Physician Services: PCP Office Visit	$10 copay	75%	$15 copay
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	$25 copay
Outpatient X-Ray and Lab	100%	75%	100% covered
Durable Medical Equipment	100%	75%	100% covered; $2,500 annual maximum
Retail Prescription Coverage
Generic	15% (Represented) 20% (Salaried)	15% (Represented) 20% (Salaried)	$10 copay for a 34-day supply;
Brand Name	25% if generic unavailable; 30% if generic available and medically necessary (Represented) 30% if generic unavailable; 50% if generic available and medically necessary (Salaried)	25% if generic unavailable; 30% if generic available and medically necessary (Represented) 30% if generic unavailable; 50% if generic available and medically necessary (Salaried)	$10 copay for a 34-day supply plus price difference between generic and brand
Mail-Order Prescription Coverage
Generic	10% generic; 20% brand if generic unavailable; 25% if generic available and medically necessary (Represented) 10% generic; 20% brand if generic unavailable; 40% if generic available and medically necessary (Salaried)	10% generic; 20% brand if generic unavailable; 25% if generic available and medically necessary (Represented) 10% generic; 20% brand if generic unavailable; 40% if generic available and medically necessary (Salaried)	$20 copay for 90-day supply
Brand Name	See Above	See Above	N/A
Diabetic Benefits
Insulin	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit	$10 copay
Chem. Strips/Lancets	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit	$10 copay
Home Health Care	100%	75% - limited to 100 visits per calendar year	100% covered
Mental Health
Inpatient	100% up to 30 days per calendar year	75% up to 30 days per calendar year	$25 copay for up to 30 days per calendar year; 90 days lifetime maximum
Outpatient	100% after $10 copay limited to 20 visits per calendar year	75% limited to 20 visits per calendar year	Individual - $25, Group-$10 copay; for up to 30 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	100% covered for initial course of treatment; 50% covered thereafter, 90 days lifetime maximum; 30 days per calendar year
Outpatient	100% after $10 copay - 30 visits per calendar year; 120 visits per lifetime	75% - 30 visits per calendar year; 120 visits per lifetime	100% covered for initial course of treatment; 50% covered for subsequent episodes; max. 30 visits year; 120 lifetime
Vision Care
Routine Eye Exam	VisionOne Discount Program	Not Covered	100% covered
Eyeglasses and Contact Lenses	VisionOne Discount Program	Not Covered	Not Covered
Hearing Care
Exam	Provided by National Ear Care Plan (NECP) - 1-800-999-1458	Not Covered	$5 copay
Hearing Aids	Provided by National Ear Care Plan (NECP) - 1-800-999-1458	Not Covered	Not Covered
Dental Care
Basic Services	Not Covered	Not Covered	Not Covered
Major Services	Not Covered	Not Covered	Not Covered
Preventive Services	Not Covered	Not Covered	Not Covered
Wellness Benefits	$10 Copay	Not Covered	Yes