2021 Biweekly rates for zip code
Home health care $20 copay/visit Not covered 1 visit/day up to 4 hours/visit, up to 60 visits per member/calendar year. Rehabilitation services $30 copay/visit Not covered 60 visits/calendar year for Physical & Occupational Therapy combined, 60 visits/calendar year for Speech Therapy. Habilitation services $30 copay/visit Not covered None. $40 copay, deductible waived PARTICIPATING PROVIDERS / REFERRED $40 copay, deductible waived Not Covered Not Covered PARTICIPATING PROVIDERS / REFERRED $50 copay, deductible waived HMO Deductible $1500 2012 (v07.24.12) 14.06.596.1-CA A Aetna Life Insurance Company Page 2 of 6. SALESFORCE.COM, INC.: Aetna Open Access® Aetna SelectSM. Coverage Period: -. $50 copay/visit, deductible doesn't. Ultrasound.) 190617.
$500 copay/stay ultrasound.) Aetna Choice POS II network doctors are covered under Tier 1 – Network Providers. All others are Tier 2/Out of Network. Penalty of $500 for failure to obtain pre-authorization for out-of-network care. You may be subject to balance billing. If you need help.
These rates do not apply to all Enrollees. If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment.
| Open Access® HMO - High Option | Code | Non-Postal | Postal 1 | Postal 2 |
|---|
Your 2021 benefits
| Plan Details | High Option |
|---|---|
| Preventive care copay | $0 |
| Primary care visit copay | $20 |
| Specialist visit copay | $35 |
| Maternity | |
| Prenatal Care | $0 |
| Hospital Care | $250 per day, $1000 max per stay |
| Inpatient hospital copay | $250/day, $1,000 max per stay |
| Outpatient surgery copay | $175 |
| Emergency room copay | $125 |
| Urgent care center copay | $50 |
| Lab/X-ray/diagnostic services | $20 PCP / $35 specialist ($75 for certain tests) |
| Prescription drug copays (for a 30-day supply at a retail pharmacy) | |
| Generic formulary* | $10 |
| Brand-name formulary* | $35 |
| Non-formulary* | $100 |
| For specialty drug information, see the federal plan brochure. Your plan requires the use of generic medication when a generic equivalent exists. *** Or get a 90-day supply for only 2 copays, not 3, through mail-order service or available at CVS retail. | |
| Built-in Vision | |
| Routine eye exam copay | $35 |
| Money toward prescription eyewear | You get $100 every 24 months |
| Discounts on eyeglasses, contacts, eye exams and more | Included |
| Built-in dental, too Use our Basic Dental Network. Call 1-800-537-9384 to select a dentist OR to switch to our larger PPO network at no additional cost. It's your choice! Basic - Pay a $5 copay for cleanings, fillings and X-rays when you visit your primary care dentist (PCD). PPO - After a $20 deductible per member, cleanings, fillings, and X-rays are covered at 100% with network dentists.** | |
*A formulary is a list of generic and brand-name drugs your health plan prefers. |
- Large nationwide Aetna HMO Network
- 24/7 access to doctors via phone or video with Teladoc®†
- Built-in dental and vision coverage
- Predictable costs
- No referrals to network specialists*
- Discounts on eyewear, LASIK surgery, gym memberships, massage, acupuncture, weight-loss programs and more
*A formulary is a list of generic and brand-name drugs your health plan prefers.
** Out of Network for cleanings, composite fillings and X-rays – you pay 50% of negotiated rate plus any difference between our allowance and the billed amount.
*** If you choose the brand name drug over the generic equivalent, you will owe the corresponding copay plus the difference between the generic and brand name costs. Please see the plan brochure for details.
†Teladoc® is covered at the member cost share.
] Teladoc and Teladoc physicians are independent contractors and are neither agents nor employees of Aetna. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.
Health insurance plans are offered, underwritten and/or administered by Aetna Life Insurance Company (Aetna).
This is a brief description of the features of this Aetna health benefits plan. Before making a decision, please read the Plan's applicable Federal brochure(s). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. Plan features and availability may vary by location and are subject to change. Pharmacy clinical programs such as precertification, step therapy, and quantity limits may apply to your prescription drug coverage. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Discount programs are neither offered nor guaranteed under our contract with the FEHB Program, but are made available to all enrollees and their families who become members under an Aetna Health Insurance Plan. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Incentive-based activity awards will only be given for completing select wellness programs as determined by the plan sponsor. Information is believed to be accurate as of the production date; however, it is subject to change.
Aetna Ultrasound Guidelines
Postal and Non-Postal rates
Aetna Ultrasound Copay Cards
- Non-Postal rates apply to most non-Postal employees.
- Postal rates apply to United States Postal Service employees.
- Postal Category 1 rates apply to career bargaining unit employees represented by the APWU, IT/AS, NALC and NPMHU.
- Postal Category 2 rates apply to career bargaining unit employees represented by the PPOA.
- Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career employees represented by the NRLCA agreement.
