| Aetna Global Benefits |
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| Summary of
Medical Benefits |
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| Plan
Features |
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Care provided
OUTSIDE THE U.S.A. |
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Care
provided
WITHIN THE U.S.A. |
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Care
provided by
Preferred Provider |
Care provided by
Non-Preferred Provider |
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Deductible
Limits - Paid by Member
(per calendar year) |
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| Individual |
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$100 |
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$100 |
$300 |
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| Family |
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$300 |
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$300 |
$900 |
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| Inpatient
Hospital Deductible |
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$0 |
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$0 |
$250 |
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| Coinsurance
Limits - Paid by Member (per calendar year)* |
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| Individual |
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$500 |
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$500 |
$1,500 |
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| Family |
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$1,500 |
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$1,500 |
$4,500 |
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| *Does
not include outpatient prescription drug expenses |
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| Lifetime
Maximum |
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$1,000,000 |
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$1,000,000 |
$1,000,000 |
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| Physician
Services |
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Non-surgical
office visits -
excluding A/D/MN |
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90% |
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100% - $10 copay |
70% |
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| Other
Charges |
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90% |
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90% |
70% |
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| Hospital
Services |
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| Inpatient |
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90% |
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90% |
70% |
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| Outpatient |
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90% |
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90% |
70% |
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| Other
Medical Expenses |
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90% |
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80% |
80% |
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| Alcohol,
Drug Abuse, Mental Disorders |
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| Inpatient
- 30 days calendar year max |
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90% |
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90% |
70% |
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| Outpatient
- $5,000 per lifetime |
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80% |
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80% |
80% |
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| Skilled
Nursing Facility |
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| Inpatient
- 120 days calendar year max |
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90% |
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90% |
70% |
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| Hospice
Care |
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| Inpatient
- 30 days per lifetime |
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90% |
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90% |
70% |
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| Outpatient
- $5,000 per lifetime |
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90% |
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90% |
70% |
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| Home
Health Care |
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| Outpatient
- 120 visits calendar year max |
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90% |
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90% |
70% |
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| Wellness |
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Routine
Physical Exams
(includes immunizations);
see schedule of details below |
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90% |
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100% - $10 copay |
70% |
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Schedule of details - Routine Physical Exams:
•Children up to age 18: 6 exams in first 12 months of life; 2 exams in 13th
- 24th months of life; 1 exam every 12 months thereafter |
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| •Children age 18+ and adults up to age 65: 1 exam every 24
months |
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| •Adults age 65+: 1 exam every 12 months |
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Routine
Gynecological Exams &
Pap Smears |
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1 annual exam and pap smear |
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Routine
Mammograms
(females age 40+) |
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1 screening per calendar year |
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| Routine
Digital Rectal Exam (DRE) & Prostate Specific Antigen (PSA) Test (males
age 40+) |
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1 test per calendar year |
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| Routine
Hearing Exam |
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1 exam every 24 months |
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| Routine
Eye Exam |
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100% benefit with 1 exam every 24 months |
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| Eyewear |
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100% benefit with
no deductible up to $100
maximum every 24 months |
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| Prescription
Drugs (includes contraceptives) |
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80% |
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100% after copay* |
80% |
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| *Using the U.S. Aetna Pharmacy Management Network - $10 generic
/ $20 brand name |
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| Maternity
Expenses |
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90% |
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90% |
70% |
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| Covered as any other medical expense and is provided for an
employee and spouse and all female family members. Pregnancy benefits do not continue to be payable after coverage
ends except in the event of total disability. In addition, coverage is
provided for diagnosis and treatment of underlying cause(s) of infertility. |
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| Emergency
Assistance Services |
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100% with no deductible |
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| Medical
Emergency Services |
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Evacuation,
provider referrals, transportation after evacuation, confinement visitation,
return of dependent children, emergency medication, vaccine and blood
transfers, hospital deposit and emergency cash advance and repatriation. |
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| Non-Medical
Emergency Services |
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Legal referral
assistance, translation services, travel assistance, emergency message
transmittal, assistance with travel documents (lost or stolen passports;
obtaining visas). |
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