June 1, 2008
AETNA CHOICE POS II (OPEN ACCESS) MEDICAL PLAN
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Effective June 1, 2008, Trinity University contracted with Aetna to process our claims and as our Aetna Choice POS II (Open Access) Network Provider. There are three plan options available to you and your family.
Trinity University also provides World Traveler Premier Plus benefits through Aetna Global Benefits at no additional cost to you. This international business travel plan provides medical benefits and health related services to employees traveling internationally on business for a period of six months or less.
ID cards were mailed to covered employee's home addresses
on May 23, 2008.
You may also visit http://www.aetna.com to register and print a temporary ID card.
The following summary indicates what the Aetna 90 Plan would pay for specific procedures.
AETNA 90 PLAN
MEDICAL PLAN SUMMARY
When Using a
When Using a
PPO Provider
Non-PPO Provider
Primary Doctor Copay $20 70% after deductible
Specialist Copay $40 70% after deductible
Lab/X-Ray
100% after deductible 70% after deductible
(diagnostic)
MRIs, MRAs, CAT, 90% after
deductible if billed by 70% after deductible
PET Scans at inpatient or outpatient
facility
*Certain diagnostic tests/outpatient procedures require prior authorization
Mammograms, PSA
No charge, no plan deductible,
No charge, no plan deductible;
& Pap Test
if billed by independent diagnostic
subject to UCR
facility or outpatient hospital
.
*May not be covered at 100% if billed with a diagnostic
code
Wellness/Preventive 100%
No charge, no plan deductible;
*well child care, immunizations, No charge, no plan deductible
subject to UCR
routine exams, charges for lab/x-ray
regardless of place of service
Urgent Care Fac. Copay
$75 Copay
70% after deductible if meets prudent layperson
definition of an emergency
ER Copay
$150 Copay $150
Copay then 90%
then 90%;
Covered at in-network level if
No plan deductible
meets prudent layperson
definition of an emergency
Inpatient Hospital
$200 Copay per admission
$400 Copay per admission then
then 90% after deductible
70% after deductible;
Precertification required.
Outpatient Hospital 90%
after deductible
70% after deductible
or Facility
Pre-Admission Testing 90% after deductible 70% after deductible
Anesthesiologist 90% after deductible 70% after deductible
Maternity Care 90% after deductible 70% after deductible
Sonograms 90% after
deductible 70% after deductible
*Up to 2 per pregnancy then
must
be medically necessary
Outpatient Surgery 90% after deductible 70% after deductible
**Individual Deductible $400 $1,200
**Family Deductible $800 $2,400
**Individual Out-of-Pocket $2,500 $9,000
**Family Out-of-Pocket $5,000 $18,000
Co-Insurance 90%/10% 70%/30%
Durable Medical Equip.
90% after deductible 70% after deductible
*subject to $10,000 max with approval
Hearing Aids
90% after deductible
70% after deductible
*subject to $1,500 lifetime maximum
Home Health
90% after deductible 70% after deductible
*16 hour max per day
Skilled Nursing,
90% after deductible 70% after deductible
Rehabilitation Hospital
& Sub-Acute Facilities
*60 day limit per year; combined for all
facilities
Hospice 100% .
100%
*Life expectancy of 6 No plan deductible
No plan deductible
months or less
Inpatient Mental Health
$200 Copay per admission
$400 Copay per admission then
*30 day limit per year then 90% after deductible
70% after deductible;
Precertification required
Outpatient Mental Health
$40 Specialist Copay 70% after deductible
*30 visit limit per year
Substance Abuse
*50,000 lifetime maximim
Inpatient $200 Copay per admission
$400 Copay per admission
then 90% after deductible
then 70% after deductible
Outpatient $40 Specialist Copay
70% after deductible
*30 visits max per year
Ambulance 90% after deductible 90% after deductible
Chiropractic
$20 Copay
70% after deductible
*30 visit limit per year
Physical, Speech & $20 Copay 70% after deductible
Occupational Therapy
Acupuncture/Acupressure $25 or $50 Copay
60% after deductible
*30 visit limit per year
Allergy Testing $40 Specialist Copay 70% after deductible
Allergy Injections No Cost to You 70% after deductible
Podiatry Care $40 Specialist Copay 70% after deductible
Out of Town Physicians
Applicable Office Visit Copay 70% after deductible
or 90% after deductible if hospitalized
plus $200 Copay for hospital admission
Out of Town Hospitals
$200 Copay per admission
$400 Copay per
then 90% after deductible if hospitalized
admission then 70% after
deductible; Precertification
required
Lifetime Maximum $3,000,000
PRESCRIPTION DRUG FORMULARY
AETNA 90 PLAN
Prescription Drug Options
Base Plan Buy-Up Plan
20% Coinsurance
with
minimum & maximum copays
Set Copays
Minimum Maximum
Retail Generic $0 $15 $10
Retail Formulary $20 $45 $20
Retail Non Formulary $50 $75 $35
Minimum Maximum
Mail Order Generic $0 $30 $20
Mail Order Formulary $40 $90 $40
Mail Order Non-Formulary $100 $150 $70
Pre-Existing Conditions (In- and Out-of-Network)
A pre-existing condition is defined as any illness or injury treated or prescription drugs taken three months prior to the effective date of coverage. Employees or dependents not currently covered under the Trinity Medical Plan and all new hires will be subject to a one-year waiting period for pre-existing conditions if proof of 18 months of previous coverage within the last 63 days is not provided.
WHCRA Annual Notice
The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patient benefits for:
Ø All stages of reconstruction of the breast on which the mastectomy was performed;
Ø Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Ø Prostheses; and
Ø Treatment of physical complications of the mastectomy, including lymphedema.
Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements.
The following summary of the PPO indicates what the Aetna 80 Plan would pay for specific procedures.
AETNA 80 PLAN
MEDICAL PLAN SUMMARY
When Using a
When Using a
PPO
Provider
Non-PPO Provider
Primary Doctor Copay $25 60% after deductible
Specialist Copay $50 60% after deductible
Lab/X-Ray (diagnostic)
100% after deductible 60% after deductible
MRIs, MRAs, CAT,
80% after
deductible if done
60% after deductible
PET Scans at inpatient or outpatient facility
*Certain diagnostic tests/outpatient procedures require prior authorization
Mammograms, PSA
No charge, no plan deductible,
No charge, no plan
& Pap Test
if billed by independent diagnostic
deductible; subject to UCR
facility or outpatient hospital
*May not be covered at 100% if submitted with a
diagnostic code
Wellness/Preventive 100%
No charge, no plan
*well child care, immunizations, No charge, no plan
deductible; subject to UCR
routine exams, charges for deductible
lab/x-ray regardless of place of service
Urgent Care Fac. Copay $75 Copay 60% after
deductible if meets
prudent layperson definition of an emergency
ER Copay
$150 Copay per admission $150
Copay
then 80%
then 80%
No plan deductible
covered at in-network level if
meets prudent layperson
definition of an emergency
Inpatient Hospital
$200 Copay per admission
$400 copay per admission
then 80% after deductible
then 60% after deductible;
Precertification required
Outpatient Hospital
80% after deductible
60% after deductible
or Facility
Pre-Admission Testing 80% after deductible 60% after deductible
Anesthesiologist 80% after deductible 60% after deductible
Maternity Care 80% after deductible 60% after deductible
Sonograms
80% after deductible
60% after deductible
*Up to 2 per pregnancy then must
be medically necessary
Outpatient Surgery 80% after deductible 60% after deductible
**Individual Deductible $800 $1,800
**Family Deductible $1,200 $3,600
**Individual Out-of-Pocket $5,000 $14,000
**Family Out-of-Pocket $10,000 $28,000
Co-Insurance 80%/20% 60%/40%
Durable Medical Equip.
80% after deductible
60% after deductible
subject to $10,000 max per year with approval
Home Health 80% after deductible 60% after deductible
Skilled Nursing,
80% after deductible
60% after deductible
Rehabilitation Hospital
& Sub-Acute Facilities
*60 day limit per year; combined for
all facilities
Hospice 100%
100%
*Life expectancy of 6 months or less No
plan deductible
No plan deductible
Inpatient Mental Health $200 Copay per admission
$400 Copay per admission then
then
80% after deductible
60% after deductible;
*30 day limit
Precertification required
Outpatient Mental Health
$50 Copay
60% after deductible
*300 visit limit per year
Substance Abuse
*$50,000 lifetime maximum
Inpatient $200 Copay per admission $400 Copay per admission then
*30 days max per year then 80% after deductible
60% after deductible;
Precertification required
Outpatient $50 Copay
60% after deductible
Ambulance 80% after deductible 80% after deductible
Chiropractic Services
$25 Copay
60% after deductible
*30 visit limit per year
Physical, Speech & $25
Office Visit Copay
60%
after deductible
Occupational Therapy
Acupuncture/Acupressure
$25 or $50 Copay
60% after deductible
*30 visit limit per year
Allergy Testing $50 Specialist Copay 60% after deductible
Allergy Injections No Cost to You 60% after deductible
Podiatry Care $50 Copay 60% after deductible
Out of Town Physicians
Applicable Office Visit Copay 60% after deductible
or 80% after deductible if hospitalized
plus $200 Copay for hospital admission
Out of Town Hospitals
$200 Copay per admission
$400 Copay per admission then
then 80% after deductible
60% after deductible;
Precertification required
Lifetime Maximum $3,000,000
PRESCRIPTION DRUG FORMULARY
AETNA 80 PLAN
Prescription Drug Options
Base Plan Buy-Up Plan
20% Coinsurance with
minimum & maximum copays
Set Copays
Minimum Maximum
Retail Generic $0 $15 $10
Retail Formulary $20 $45 $20
Retail Non Formulary $50 $75 $35
Minimum Maximum
Mail Order Generic $0 $30 $20
Mail Order Formulary $40 $90 $40
Mail Order Non-Formulary $100 $150 $70
Pre-Existing Conditions (In- and Out-of-Network)
A pre-existing condition is defined as any illness or injury treated or prescription drugs taken three months prior to the effective date of coverage. Employees or dependents not currently covered under the Trinity Medical Plan and all new hires will be subject to a one-year waiting period for pre-existing conditions if proof of 18 months of previous coverage within the last 63 days is not provided.
WHCRA Annual Notice
The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patient benefits for:
Ø All stages of reconstruction of the breast on which the mastectomy was performed;
Ø Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Ø Prostheses; and
Ø Treatment of physical complications of the mastectomy, including lymphedema.
Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements.
The following summary of the PPO indicates what the AETNA 70 Plan would pay for specific procedures.
AETNA 70 PLAN
MEDICAL PLAN SUMMARY
When Using
a When Using a
PPO
Provider Non-PPO Provider
Primary Doctor Copay $30 50% after deductible
Specialist Copay $60 50% after deductible
Lab/X-Ray (diagnostic)
70% after deductible 50% after deductible
MRIs, MRAs, CAT,
70% after
deductible if done
50% after deductible
PET Scans at inpatient or outpatient facility
*Certain diagnostic tests/outpatient procedures require prior authorization
Mammograms, PSA
No charge, no plan deductible,
No charge, no plan
& Pap Test
if billed by independent diagnostic
deductible; subject to UCR
facility or outpatient hospital
*May not be covered at 100% if billed with a diagnostic code
Wellness/Preventive 100%
100%
*well child care, immunizations, No charge, no plan
deductible
No charge, no plan deductible;
routine exams,
subject to UCR
lab/x-ray billed by physician's office
Urgent Care Fac. Copay $75 Copay
50% after deductible if meets prudent layperson
definition of an emergency
ER Copay
$150 Copay $150 Copay
then 70%
then 70% Covered
at in-network level if meets prudent layperson
No plan deductible
definition of an emergency
Inpatient Hospital
$200 Copay per admission
$400 copay per admission
then 70% after deductible
then 50% after deductible;
Precertification required
Outpatient Hospital
70% after deductible
50% after deductible
or Facility
Pre-Admission Testing 70% after deductible 50% after deductible
Anesthesiologist 70% after deductible 50% after deductible
Maternity Care 70% after deductible 50% after deductible
Sonograms
70% after deductible
50% after deductible
*Up to 2 per pregnancy then must
be medically necessary
Outpatient Surgery 70% after deductible 50% after deductible
**Individual Deductible $1,200 $3,600
**Family Deductible $2,400 $7,200
**Individual Out-of-Pocket $7,500 None
**Family Out-of-Pocket $15,000 None
Co-Insurance 70%/30% 50%/50%
Durable Medical Equip.
70% after deductible
50% after deductible
subject to $10,000 max per year with approval
Home Health 70% after deductible 50% after deductible
Skilled Nursing,
70% after deductible
50% after deductible
Rehabilitation Hospital
& Sub-Acute Facilities
*60 day limit per year; combined for
all facilities
Hospice 100%
100%
*Life expectancy of 6 months or less No
plan deductible
No plan deductible
Inpatient Mental Health $200 Copay per admission
$400 Copay per admission then
then
70% after deductible
50% after deductible;
*30 day limit
Precertification required
Outpatient Mental Health
$60 Copay
50% after deductible
*300 visit limit per year
Substance Abuse
*$50,000 lifetime maximum
Inpatient $200 Copay per admission $400 Copay per admission then
*30 days max per year then 70% after deductible
50% after deductible;
