Aetna Ultrasound Copay

  1. Aetna 76815 Ultrasound Policy
  2. Aetna Ultrasound Copay Program

2021 Biweekly rates for zip code

Aetna Health, Inc. BASIC HMO COPAY PLAN 1 SCHEDULE OF BENEFITS HMO/FL SMGRP-BA-COP SOB-1 05/03 1 INDIVIDUAL LIFETIME MAXIMUM BENEFIT $2 Million Dollars $5,000 Single OUT-OF-POCKET MAXIMUM EXPENSE LIMITS $10,000 Family The Covered Services set forth in this Schedule must be provided by and/or authorized by the. Childbirth/delivery facility services $100 copay/day deductible + 30% coinsurance Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. Ultrasound.) Max copay /calendar year: $300. Penalty of $500 for failure to obtain pre-authorization for out-of-network care may. ©2018 Aetna Inc. 95.03.300.1 B (2/18) Title: tA-18157hires Author: CQF Subject: Accessible PDF Keywords: PDF/UA Created Date: 2/12/2018 2:54:43 PM.

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.

Table of rates.
Open Access® HMO - High OptionCodeNon-PostalPostal 1Postal 2
Click to learn more about non-postal, postal 1 and postal 2 rates

Your 2021 benefits

Table of rates.
Plan DetailsHigh 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 eyewearYou get $100 every 24 months
Discounts on eyeglasses, contacts, eye exams and moreIncluded
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.
** 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. Please see plan brochure for details.
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.

  • 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

My router ip. *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.

Postal and Non-Postal rates

Aetna Ultrasound Copay
  • 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.
suggested for you
View the 2021 Standard Option plan

Traditional coverage. Affordable premiums.

Aetna 76815 Ultrasound Policy

With comprehensive care, this medical plan is the one you know and trust, with familiar benefits and coverage

When you enroll in GEHA’s Standard Option, you:

  • Pay nothing for online doctor visits with access to certified doctors, including dermatologists, and licensed therapists through MDLIVE.
  • Pay nothing for routine, in-network maternity care.
  • Get a complete range of prescription services.

More Standard Option highlights:

  • A 30-day supply of generic medication costs just $10.
  • You can visit your primary care doctor for only a $15 copay each visit.
  • This plan covers 100% of preventive care costs when you see an in-network provider.

2020 Rates

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 that maintains your health benefits enrollment.

Self OnlySelf Plus OneSelf and Family
Non-Postal biweekly$60.54$130.18$155.52
Postal biweekly – Category 1 $58.12$124.97$149.30
Postal biweekly – Category 2 $50.25$108.05$129.08
Monthly (retirees)$131.18$282.05$336.96

Pay nothing for online doctor visits with access to certified doctors, including dermatologists, and licensed therapists through MDLIVE.

A 30-day supply of generic medication costs just $10.

You can visit your primary care doctor for only a $15 copay each visit.

Covered benefits for routine in-network maternity care and hospital stays.

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Costs for services in 2020

The table below summarizes your in-network cost for medical benefits with GEHA Standard Option. For complete information, refer to the GEHA Plan Brochure.

Aetna Ultrasound Copay Program

Copays

CopayWhat you pay in-network
Primary physician office visit$15
Specialist$30
MinuteClinic (where available)$10
Urgent care$35
Annual eye exam$5 through EyeMed

Other services

ServiceWhat you pay in-network
Preventive lab servicesNothing with Lab Card
Well-child visit; up to age 22Nothing
Adult routine screeningNothing
Preventive dental care50% of allowance, twice yearly

Maternity care

ServiceWhat you pay in-network
Routine provider careNothing
Inpatient careNothing
Self OnlySelf Plus OneSelf and Family
Calendar-year deductible (in-network)$350$700$700
Out-of-pocket-maximum (in-network)$6,500$13,000$13,000

Prescriptions

The table below summarizes your cost for prescription drugs with GEHA’s Standard Option. For complete benefit information, including details on specialty drugs that are injected or infused, refer to the GEHA Plan Brochure.

To find a drug cost based on your benefit plan and prescription dosage, check your drug costs.

Retail pharmacy – 30-day supply

In-NetworkOut of Network
Generic$10$10, plus difference between plan allowance and cost of drug
Preferred brand-name50%, up to $200 max¤50%, up to $200 max, plus difference between plan allowance and cost of drug**¤
Non-preferred brand-name50%, up to $300 max¤50%, up to $300 max, plus difference between plan allowance and cost of drug**¤

Mail service pharmacy – 90-day supply

Does
In-NetworkOut of Network
Generic$20n/a
Preferred brand-name50%, up to $500 max¤n/a
Non-preferred brand-name50%, up to $600 max¤n/a

¤If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand-name and the generic.

**Retail fills eligible for a greater than a 30-day supply will be subject to the 50% coinsurance up to the maximum of $500 for preferred or $600 for non-preferred.

HEALTH REWARDS
Up to $250 in incentives for Standard Option members who complete simple and convenient health screenings.
VISION COVERAGE
Get in-network routine eye exams for $5 and discounts on eyewear.
GYM DISCOUNTS
Access over 10,000 fitness centers nationwide for $25 a month (plus a $25 enrollment fee and taxes).

^GEHA supplemental benefits are neither offered nor guaranteed under contract with the FEHB, but are made available to all enrollees and family members who become members of a GEHA medical plan. For information on year-round savings for GEHAdental members, visit Savings for GEHA dental members.

This is a brief description of the features of the GEHA Standard Option medical plan. Before making a final decision, please read the Plan’s Federal brochure RI 71-006. All benefits are subject to the definitions, limitations and exclusions set forth in the Federal brochure.
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