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  • Important Questions Answers Why this Matters:

    This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.aetna.com/sbcsearch/getpolicydocs?u=071000-110020-021650 or by calling 1-888-982-3862.

    In-Network: Individual $500 / Family $1,500. Out–of–Network: Individual $500 / Family $1,500. Does not apply to office visits, prescription drugs, emergency care, and preventive care in-network.

    You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

    What is the overall deductible?

    No. You don't have to meet deductibles for specific services, but see the chartstarting on page 2 for other costs for services this plan covers. Are there other deductibles for specific services?

    Yes. In-Network: Individual $3,000 / Family $9,000. Out–of–Network: Individual $6,000 / Family $18,000.

    The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

    Is there an out-of-pocket limit on my expenses?

    Premiums, balance-billed charges, penalties for failure to obtain pre-authorization for service, and health care this plan does not cover.

    Even though you pay these expenses, they don't count toward the out-of pocket limit.

    What is not included in the out-of-pocket limit?

    No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

    Is there an overall annual limit on what the plan pays?

    If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

    Does this plan use a network of providers?

    Yes. See www.aetna.com or call 1-888-982-3862 for a list of in-network providers.

    You can see the specialist you choose without permission from this plan.Do I need a referral tosee a specialist? No.

    Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services.

    Are there services this plan doesn't cover?

    Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS

    Coverage Period: 01/01/2017 - 12/31/2017

    1 of 8 071000-110020-021650

    SAN DIEGO STATE UNIVERSITY FOUNDATION DBA SAN DIEGO STATE UNIVERSITY RESEARCH FOUNDATION : Aetna Open Access® Managed Choice®

    :

    Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.

    www.aetna.com

  • Limitations & Exceptions

    Your Cost If You Use an

    Out–of–Network Provider

    Services You May Need

    Your Cost If You Use an

    In-Network Provider Common Medical Event

    40% coinsurance$15 copay/visitPrimary care visit to treat an injury orillness Includes Internist, General Physician, Family Practitioner, Pediatrician, Gynecologist or Obstetrician.

    40% coinsurance$15 copay/visitSpecialist visit –––––––––––none–––––––––––

    40% coinsurance$15 copay/visitOther practitioner office visit Coverage is limited to 20 visits for Chiropractic care and 20 visits for acupuncture per calendar year.

    40% coinsuranceNo chargePreventive care /screening/immunization

    If you visit a health care provider's office or clinic

    Age and frequency schedules may apply.

    40% coinsurance$15 copay/visit, afterdeductibleDiagnostic test (x-ray, blood work) –––––––––––none–––––––––––

    40% coinsurance$15 copay/visit, afterdeductibleImaging (CT/PET scans, MRIs) If you have a test

    –––––––––––none–––––––––––

    Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

    The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

    Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible.

    This plan may encourage you to use in-network providers by charging you lower deductibles, copayments, and coinsurance amounts.

    Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS

    Coverage Period: 01/01/2017 - 12/31/2017

    2 of 8 071000-110020-021650

    SAN DIEGO STATE UNIVERSITY FOUNDATION DBA SAN DIEGO STATE UNIVERSITY RESEARCH FOUNDATION : Aetna Open Access® Managed Choice®

    :

    Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.

  • Limitations & Exceptions

    Your Cost If You Use an

    Out–of–Network Provider

    Services You May Need

    Your Cost If You Use an

    In-Network Provider Common Medical Event

    50% coinsurance after copay/RX: $10 (retail)

    Copay/prescription (RX): $10 (retail), $20 (mail order)

    Generic drugs Covers 30 day supply (retail), 31-90 day supply (mail order). Includes contraceptive drugs & devices obtainable from a pharmacy, oral fertility drugs. No charge for formulary generic FDA-approved women's contraceptives in-network. Review your formulary for prescriptions requiring precertification or step therapy for coverage. Your cost will be higher for choosing Brand over Generics unless prescribed Dispense as Written.

    50% coinsurance after copay/RX: $25 (retail)

    Copay/RX: $25 (retail), $50 (mail order)Preferred brand drugs

    50% coinsurance after copay/RX: $50 (retail)

    Copay/RX: $50 (retail), $100 (mail order)Non-preferred brand drugs

    Not covered Applicable cost as noted above for generic or brand drugs.

    Specialty drugs

    If you need drugs to treat your illness or condition

    More information about prescription drug coverage is available at www.aetna.com/phar macy-insurance/individ uals-families

    Premier Three Tier Open Formulary

    First prescription must be filled at a participating retail pharmacy or Aetna Specialty Pharmacy Networks. Subsequent fills must be through Aetna Specialty Pharmacy Networks.

    40% coinsurance20% coinsuranceFacility fee (e.g., ambulatory surgerycenter) –––––––––––none–––––––––––

    40% coinsurance20% coinsurancePhysician/surgeon fees

    If you have outpatient surgery

    –––––––––––none––––––––––– $100 copay/visit$100 copay/visitEmergency room services No coverage for non-emergency use. 20% coinsurance20% coinsuranceEmergency medical transportation No coverage for non-emergency transport. 40% coinsurance$25 copay/visitUrgent care

    If you need immediate medical attention No coverage for non-urgent use.

    40% coinsurance20% coinsuranceFacility fee (e.g., hospital room) Pre-authorization required forout-of-network care. 40% coinsurance20% coinsurancePhysician/surgeon fee

    If you have a hospital stay

    –––––––––––none–––––––––––

    Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: POS

    Coverage Period: 01/01/2017 - 12/31/2017

    3 of 8 071000-110020-021650

    SAN DIEGO STATE UNIVERSITY FOUNDATION DBA SAN DIEGO STATE UNIVERSITY RESEARCH FOUNDATION : Aetna Open Access® Managed Choice®

    :

    Questions: Call 1-888-982-3862 or visit us at www.HealthReformPlanSBC.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.HealthReformPlanSBC.com or call 1-888-982-3862 to request a copy.

    https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage http://www.aetna.com/pharmacy-insurance/individuals-families http://www.aetna.com/pharmacy-insurance/individuals-families http://www.aetna.com/pharmacy-insurance/individuals-families

  • Limitations & Exceptions

    Your Cost If You Use an

    Out–of–Network Provider

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