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2021 Benefits summary

Benefits schedule for the Retiree Medical Plan - Aetna Select option

All non-emergency specialty and hospital services require a prior referral from your PCP. Call member services to inquire if a referral is required prior to the services being rendered.

Type of Service or Supply Benefit Level
Lifetime Maximum No lifetime maximum
Individual Annual Out-of-Pocket Maximum (Includes Pharmacy) $3,000
Family Annual Out-of-Pocket Maximum Includes Pharmacy) $6,000 
If a retiree and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%. 
Preventive Care
Preventive Care Office Visits
No charge 
Routine Physicals & Immunizations
No charge  
Well Woman Care (including Pap Smear Test)
No charge (direct access / no referral)  
Mammograms
No charge  
Well Baby Care (including Immunizations)
No charge  
Prostate Cancer Screening No charge     
Primary Care 
PCP Office Visits - Including Telemedicine $25 copay per visit
Allergy Treatment- Routine injections at PCP’s office, with or without physician encounter $25 copay per visit
Eyeglasses/Contact Lenses Age 0-18 – one set of lenses and frames or contacts per calendar year Age 19 and over - one set of lenses and frames or contacts every 24 months
Hearing Aids Not covered (See Exclusions section for information about the Amplifon Hearing Health Care (formerly HearPo) Discount Program and the Hearing Care Solutions Discount Program)
Specialty And Outpatient Care
Specialist Office Visits - Including Telemedicine $40 copay per visit
Walk in Clinic (Retail Clinic) $40 copay per visit
Prenatal Care (applies to standard global maternity services and initial visit) $40 copay per visit (no referral required)
Maternity (childbirth/delivery services) 90% coverage 
Allergy Testing $40 copay per visit
Imaging (CT/PET scans, MRIs) 90% coinsurance
Some tests may require prior approval by Aetna
Diagnostic X-rays and Outpatient Labs associated with an office visit No additional charge
Therapy (speech, occupational, physical) $40 copay per visit
Chiropractic Care $40 copay per visit - 20 visits per calendar year
Outpatient Rehabilitation $40 copay per visit
Home Health Care

90% coinsurance

Skilled Nursing Care 90% coverage  
Prosthetic Devices 90% coinsurance
To see a list of procedures that require precertification, please reference the National Precertification List* on the Aetna member website.
Inpatient Services (Precertification required)
Hospital Room and Board and Other Inpatient Services 90% coverage
Skilled Nursing Facilities 90% coverage
Hospice Facility 90% coverage  
Surgery and Anesthesia
Inpatient Surgery 90% coverage  
Outpatient Surgery 90% coverage  
Mental Health and Substance Use Treatment
Office Visit
$25 or $40 copay per visit 
Outpatient Services 90% coverage   
Inpatient Treatment (including residential treatment centers) 90% coverage
Urgent and Emergency Care
Urgent Care $60 copay per visit  
Emergency Room $150 copay (waived if admitted)
Ambulance 90% coverage
Prescription Drugs through Express Scripts (No annual maximum benefit)
Annual out-of-pocket maximum Combined with medical out-of-pocket maximum
Short-term (30-day supply)* ** $15 copay – generic formulary drugs
30% copay – brand-name formulary drugs. $145 maximum per prescription
45% copay – non-formulary drugs. $165 maximum per prescription
Long-term (90-day supply)* $30 copay – generic formulary drugs
30% copay – brand-name formulary drugs. $145 maximum per prescription
45% copay – non-formulary drugs. $165 maximum per prescription

National Precertification List on the Aetna member website

* If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum.

** A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.

*** Formulary means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.

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