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 FeaturesCare 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
$1500$3000
Family$3750$3750$7500
*Does not include outpatient
prescription drug expenses
Lifetime MaximumUnlimitedUnlimitedUnlimited
Physician Services
Non-surgical office visits90%$25 Copay Primary Care
$50 Copay Specialist Care
70%
Other Charges90%90%70%
Hospital Services
Inpatient90%90% after a $350 Co-pay70% after a $350 deductible
Outpatient90%90% after a $100 Co-pay70% after a $100 deductible
Other Medical Expenses90%80%80%
Alcohol, Drug Abuse, Mental Disorders
Inpatient90%90% after a $350 Co-pay70% after a $350 deductible
Outpatient90%90% after a $100 Co-pay70% after a $100 deductible
Skilled Nursing Facility
Inpatient - 120 days calendar year max90%90% after a $350 Co-pay70% after a $350 deductible
Hospice Care
Inpatient90%90% after a $350 Co-pay70% after a $350 deductible
Outpatient90%90% after a $100 Co-pay70% after a $100 deductible
Home Health Care
Outpatient - 120 visits calendar year max90%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 Exam1 exam every
24 months
Routine Eye Exam100% benefit with
1 exam every 24 months
Eyewear100% 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
Maternity Expenses90%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 deductibleNot ApplicableNot Applicable
Medical Emergency ServicesServices for Medical Evacuation are not covered. All Med-evac arrangements are handled by the post.
Non-Medical Emergency ServicesLegal 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, 2022:

Monthly TotalPer Paycheck
Single$658.35
$329.18
Employee & Spouse$1682.59$841.30
Employee & Child(ren)$1407.90$703.95
Family$2583.46$1291.73
Monthly COBRA Premiums:
Single$671.52
Employee & Spouse$1716.24
Employee & Child(ren)$1436.06
Family$2635.13