The Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this Plan Summary document will tell you about some of the important features of the Plan, other features that may be important to you are defined in the Certificate. To look at the full Plan description, which is contained in the Certificate issued to you, go to .
This Plan will pay benefits in accordance with any applicable Ohio Insurance Law(s).
|
Policy year deductible |
In-network coverage |
Out-of-network coverage |
|---|---|---|
|
You have to meet your policy year deductible before this plan pays for benefits. |
||
|
Student |
$400 per policy year |
$750 per policy year |
|
Spouse |
$400 per policy year |
$750 per policy year |
|
Each Child |
$400 per policy year | $750 per policy year |
|
Family |
$1,200 per policy year | $2,250 per policy year |
Individual
This is the amount you owe for in-network and out-of-network eligible health services each policy year before the plan begins to pay for eligible health services. This policy year deductible applies separately to you and each of your covered dependents. After the amount you pay for eligible health services reaches the policy year deductible, this plan will begin to pay for eligible health services for the rest of the policy year. This is true even if the family policy year deductible has not yet been met.
Family
This is the amount you and your covered dependents owe for in-network and out-of-network eligible health services each policy year before the plan begins to pay for eligible health services. After the amount you and your covered dependents pay for eligible health services reaches this family policy year deductible, this plan will begin to pay for eligible health services that you and your covered dependents incur for the rest of the policy year.
To satisfy this family policy year deductible limit for the rest of the policy year, the following must happen:
- The combined eligible health services that you and each of your covered dependents incur towards the individual policy year deductibles must reach this family policy year deductible limit in a policy year.
When this occurs in a policy year, the individual policy year deductibles for you and your covered dependents will be considered to be met for the rest of the policy year.
Eligible health services applied to the out-of-network policy year deductibles will not be applied to satisfy the in-network policy year deductibles. Eligible health services applied to the in-network policy year deductibles will not be applied to satisfy the out-of-network policy year deductibles.
Policy Year Deductible Waiver
The policy year deductible is waived for all of the following eligible medical services:
- In-network care for Preventive care and wellness
- In-network care for Pediatric dental care
- In-network care and out-of-network care for Pediatric vision car
- In-network care and out-of-network care for Outpatient prescription drugs
Maximum Out-of-Pocket Limits
|
Maximum out-of-pocket limit per policy year |
||
|---|---|---|
|
Student |
$5,000 per policy year |
$15,000 per policy year |
| Spouse | $5,000 per policy year |
$15,000 per policy year |
|
Each child |
$5,000 per policy year | $15,000 per policy year |
|
Family |
$10,000 per policy year |
$30,000 per policy year |
Eligible health services applied to the out-of-network maximum out-of-pocket limit will not be applied to satisfy the in-network maximum out-of-pocket limit and eligible health services applied to the in-network maximum out-of-pocket limit will not be applied to satisfy the out-of-network maximum out-of-pocket limit
Precertification Covered Benefit Penalty
This only applies to out-of-network coverage: The certificate of coverage contains a complete description of the precertification program. You will find details on precertification requirements in the Medical necessity and precertification requirements section.
Failure to precertify your eligible medical services when required will result in the following benefit penalties: The additional percentage or dollar amount of the recognized charge which you may pay as a penalty for failure to obtain precertification is not a covered benefit, and will not be applied to the policy year deductible amount or the maximum out-of-pocket limit, if any.
Schedule of Benefits
The coinsurance listed in the below reflects the plan coinsurance percentage. This is the coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.
View full schedule of benefits in the
A covered person, a covered person's designee or a covered person's prescriber may seek an expedited medical exception process to obtain coverage for non-covered drugs in exigent circumstances. An "exigent circumstance" exists when a covered person is suffering from a health condition that may seriously jeopardize a covered person's life, health, or ability to regain maximum function or when a covered person is undergoing a current course of treatment using a non-formulary drug.
The request for an expedited review of an exigent circumstance may be submitted by contacting Aetna's Pre-certification Department at 855.240.0535, faxing the request to 877.269.9916, or submitting the request in writing to:
CVS Health
ATTN: Aetna PA
1300 E Campbell Road
Richardson, TX 75081