International Health, Rx, and Dental Plan
Plan Basics:
An eligible employee and his or her dependents may enroll in the PPO plan through Aetna International Global Benefits. This plan includes coverage anywhere in the world, 24/7. Enrolled dependents that remain in the United States may utilize health or dental providers from the Aetna PPO nationwide network, or they may receive care from a non-network provider. Doctors or other providers for the Aetna PPO network may be found here: www.aetna.com/docfind
There are three main ways to receive benefits through the plan. You may use a network provider or a non-network provider while in the United States. If you are outside the United States, you may be eligible for benefits when treatment for you or a dependent, is dispensed by a provider that is licensed by the country where treatment is takes place.
Summary of Aetna International Plan Benefits
| Plan Features | Care provided Outside the U.S.A. | Care provided Within the U.S.A. | Care provided Within the U.S.A. |
| Care provided by Preferred Provider | Care provide by Non-Preferred Provider |
||
| Deductible Limits - Paid by Member (per calendar year) | |||
| Individual | $0 | $0 | $0 |
| Family | $0 | $0 | $0 |
| Out of Pocket Limits - Paid by Member (per calendar year)* | |||
| Individual | $1500 | $2000 | $3500 |
| Family | $3750 | $4000 | $7000 |
| *Does not include outpatient prescription drug expenses | |||
| Lifetime Maximum | Unlimited | Unlimited | Unlimited |
| Physician Services | |||
| Non-surgical office visits | 90% | $25 Copay Primary Care $50 Copay Specialist Care | 70% |
| Other Charges | 90% | 90% | 70% |
| Hospital Services | |||
| Inpatient | 90% | 90% after a $350 Co-pay | 70% after a $350 deductible |
| Outpatient | 90% | 90% after a $100 Co-pay | 70% after a $100 deductible |
| Other Medical Expenses | 90% | 80% | 80% |
| Alcohol, Drug Abuse, Mental Disorders | |||
| Inpatient | 90% | 90% after a $350 Co-pay | 70% after a $350 deductible |
| Outpatient | 90% | 90% after a $100 Co-pay | 70% after a $100 deductible |
| Skilled Nursing Facility | |||
| Inpatient - 120 days calendar year max | 90% | 90% after a $350 Co-pay | 70% after a $350 deductible |
| Hospice Care | |||
| Inpatient | 90% | 90% after a $350 Co-pay | 70% after a $350 deductible |
| Outpatient | 90% | 90% after a $100 Co-pay | 70% after a $100 deductible |
| Home Health Care | |||
| Outpatient - 120 visits calendar year max | 90% | 90% | 70% |
| Wellness | |||
| Routine Physical Exams (includes immunizations); see schedule of details below | 90% | 100% | 70% |
| 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 | |||
| •Children age 18+ and adults up – 1 exam every 12 months | |||
| Routine Gynecological Exams & Pap Smears | 1 annual exam and pap smear | ||
| Routine Mammograms (females age 40+) | 1 screening per calendar year | ||
| Routine Digital Rectal Exam (DRE) & Prostate Specific Antigen (PSA) Test (males age 40+) | 1 test per calendar year | ||
| Routine Hearing Exam | 1 exam every 24 months | ||
| Routine Eye Exam | 100% benefit with 1 exam every 24 months | ||
| Eyewear | 100% for eyewear, not subject to deductible, up to $250 every 24 months | ||
| Prescription Drugs (includes contraceptives) | 80% | 100% after copay* | 80% |
| *Using the U.S. Aetna Pharmacy Network. co-pays of $15 generic / $45 preferred brand /$60 non-preferred brand /$150 specialty medications | |||
| Maternity Expenses | 90% | 90% | 70% |
| Covered as any other medical expense and is provided for an employee and spouse and all female family members. In addition, coverage is provided for diagnosis only of underlying cause(s) of infertility. | |||
| Emergency Assistance per policy benefits Services | 100% with no deductible | Not Applicable | Not Applicable |
| Medical Emergency Services | Services for Medical Evacuation are not covered. All Med-evac arrangements are handled by the post. | ||
| Non-Medical Emergency Services | Legal referral assistance, translation services, travel assistance, emergency message transmittal, assistance with travel documents (lost or stolen passports; obtaining visas). |
Click here for a Complete Version of the Policy: policy-benefits-oct2013
Click here for a Summary Plan Description: Summary Grid 2020
Monthly Premiums for the plan year ending September 30, 2025:
| Monthly Total | Per Paycheck | |
| Single | $667.88 | $333.94 |
| Employee & Spouse | $1706.65 | $853.33 |
| Employee & Child(ren) | $1438.84 | $719.42 |
| Family | $2620.64 | $1310.32 |
| Monthly COBRA Premiums: | ||
| Single | $681.24 | |
| Employee & Spouse | $1740.78 | |
| Employee & Child(ren) | $1467.61 | |
| Family | $2673.05 |