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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
INFRAMARK, LLC : Aetna Premier Care Network Choice® POS II -
Enhanced PPO Plan
Coverage Period: 01/01/2024-12/31/2024
Coverage for: Individual + Family | Plan Type: POS
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share
the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only
a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.HealthReformPlanSBC.com or by calling 1-
888-982-3862. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-888-982-3862 to request a copy.
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
Aetna Premier Care Network In-Network:
Individual $1,500 / Family $4,500. Out-of-
Network: Individual $4,500 / Family $13,500.
Generally, you must pay all of the costs from providers up to the deductible amount
before this plan begins to pay. If you have other family members on the plan, each
family member must meet their own individual deductible until the total amount of
deductible expenses paid by all family members meets the overall family deductible.
Are there services covered
before you meet your
deductible?
Yes. Emergency care & preventive care; plus
in-network office visits are covered before you
meet your deductible.
This plan covers some items and services even if you haven't yet met the deductible
amount. But a copayment or coinsurance may apply. For example, this plan covers
certain preventive services without cost sharing and before you meet your deductible.
See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/
Are there other deductibles
for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
Aetna Premier Care Network In-Network:
Individual $4,500 / Family $9,000. Out-of-
Network: Individual $9,000 / Family $27,000.
The out–of–pocket limit is the most you could pay in a year for covered services. If you
have other family members in this plan, they have to meet their own out–of–pocket
limits until the overall family out–of–pocket limit has been met.
What is not included in the
out-of-pocket limit?
Premiums, balance-billing charges, health care
this plan doesn't cover & penalties for failure to
obtain pre-authorization for services.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you use a
network provider?
Yes. See www.aetna.com/docfind or call 1-888-
982-3862 for a list of Aetna Premier Care
Network In-network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might
receive a bill from a provider for the difference between the provider's charge and what
your plan pays (balance billing). Be aware, your network provider might use an out-of-
network provider for some services (such as lab work). Check with your provider
before you get services.
Do you need a referral to see
a specialist?
No.
You can see the specialist you choose without a referral.
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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical
Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Aetna Premier
Care Network In-
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay the
most)
If you visit a health
care provider’s
office or clinic
Primary care visit to treat an injury or illness
$25 copay/visit,
deductible doesn't
apply
50% coinsurance
None
Specialist visit
$50 copay/visit,
deductible doesn't
apply
50% coinsurance
None
Preventive care /screening /immunization
No charge
No charge
You may have to pay for services that aren't
preventive. Ask your provider if the services
needed are preventive. Then check what your
plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
20% coinsurance
50% coinsurance
None
Imaging (CT/PET scans, MRIs)
20% coinsurance
50% coinsurance
None
If you need drugs
to treat your
illness or
condition
More information
about prescription
drug coverage is
available at
www.aetna.com/pha
rmacy-
insurance/individual
s-families
Generic drugs
Not covered
Not covered
Not covered.
Preferred brand drugs
Not covered
Not covered
Non-preferred brand drugs
Not covered
Not covered
Specialty drugs
Not covered
Not covered
Not covered.
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
50% coinsurance
None
226387-987004-949053 Page 3 of 6
Common Medical
Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Aetna Premier
Care Network In-
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay the
most)
If you have
outpatient surgery
Physician/surgeon fees
20% coinsurance
50% coinsurance
None
If you need
immediate medical
attention
Emergency room care
$350 copay/visit,
deductible doesn't
apply
$350 copay/visit,
deductible doesn't
apply
Out-of-network emergency use paid the same as
in-network. No coverage for non-emergency use.
Emergency medical transportation
20% coinsurance
20% coinsurance
Out-of-network emergency use paid the same as
in-network.
Urgent care
$100 copay/visit,
deductible doesn't
apply
50% coinsurance
No coverage for non-urgent use.
If you have a
hospital stay
Facility fee (e.g., hospital room)
20% coinsurance
50% coinsurance
Penalty of $400 for failure to obtain pre-
authorization for out-of-network care.
Physician/surgeon fees
20% coinsurance
50% coinsurance
None
If you need mental
health, behavioral
health, or
substance abuse
services
Outpatient services
Office: $25
copay/visit,
deductible doesn't
apply; other
outpatient services:
20% coinsurance
Office & other
outpatient services:
50% coinsurance
None
Inpatient services
20% coinsurance
50% coinsurance
Penalty of $400 for failure to obtain pre-
authorization for out-of-network care.
If you are pregnant
Office visits
No charge
50% coinsurance
Cost sharing does not apply for preventive
services. Maternity care may include tests and
services described elsewhere in the SBC (i.e.,
ultrasound), including outpatient hospital
services. Penalty of $400 for failure to obtain pre-
authorization for out-of-network care may apply.
Childbirth/delivery professional services
20% coinsurance
50% coinsurance
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
If you need help
recovering or have
Home health care
20% coinsurance
50% coinsurance
100 visits/calendar year. Penalty of $400 for
failure to obtain pre-authorization for out-of-
network care.
226387-987004-949053 Page 4 of 6
Common Medical
Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Aetna Premier
Care Network In-
Network Provider
(You will pay the
least)
Out-of-Network
Provider
(You will pay the
most)
other special
health needs
Rehabilitation services
$25 copay/visit,
deductible doesn't
apply
50% coinsurance
90 visits/calendar year for Physical, Occupational
& Speech Therapy combined, including
outpatient hospital services.
Habilitation services
20% coinsurance
50% coinsurance
None
Skilled nursing care
20% coinsurance
50% coinsurance
60 days/calendar year. Penalty of $400 for failure
to obtain pre-authorization for out-of-network
care.
Durable medical equipment
20% coinsurance
50% coinsurance
Limited to 1 durable medical equipment for
same/similar purpose. Excludes repairs for
misuse/abuse.
Hospice services
20% coinsurance
50% coinsurance
Penalty of $400 for failure to obtain pre-
authorization for out-of-network care.
If your child needs
dental or eye care
Children's eye exam
Not covered
Not covered
Not covered.
Children's glasses
Not covered
Not covered
Not covered.
Children's dental check-up
Not covered
Not covered
Not covered.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Acupuncture
• Cosmetic surgery
• Dental care (Adult & Child)
• Glasses (Child)
• Long-term care
• Non-emergency care when traveling outside
the U.S.
• Prescription Drugs
• Private-duty nursing
• Routine eye care (Adult & Child)
• Routine foot care
• Weight loss programs - Except for required preventive
services.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
226387-987004-949053 Page 5 of 6
• Bariatric surgery - Limited to in-network
providers.
• Chiropractic care
• Hearing aids - $3,500 maximum/3 years.
• Infertility treatment - Limited to the diagnosis & treatment of
underlying medical condition.
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is:
• For more information on your rights to continue coverage, contact the plan at 1-888-982-3862.
• If your group health coverage is subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA
(3272)
or http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should
contact their State insurance regulator regarding their possible rights to continuation coverage under State law.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance
or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete
information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
• If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general number
at 1-888-982-3862. You may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or
http://www.dol/gov/ebsa/healthreform
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• Additionally, a consumer assistance program can help you file your appeal. Contact information is at:
http://www.aetna.com/individuals-families-health-insurance/rights-resources/complaints-grievances-appeals/index.html.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
To see examples of how this plan might cover costs for a sample medical situation, see the next section
226387-987004-949053 Page 6 of 6
Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to reduce
your costs. For more information about the wellness program, please contact: 1-888-982-3862.
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
◼ The plan's overall deductible $1,500
◼ Specialist copayment $50
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$1,500
Copayments
$0
Coinsurance
$2,000
What isn't covered
Limits or exclusions
$70
The total Peg would pay is
$3,570
◼ The plan's overall deductible $1,500
◼ Specialist copayment $50
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Diabetic supplies (glucose meter)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$100
Copayments
$300
Coinsurance
$0
What isn't covered
Limits or exclusions
$4,300
The total Joe would pay is
$4,700
◼ The plan's overall deductible $1,500
◼ Specialist copayment $50
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$900
Copayments
$500
Coinsurance
$0
What isn't covered
Limits or exclusions
$10
The total Mia would pay is
$1,410
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Managing Joe’s Type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
Mia’s Simple Fracture
(in-network emergency room visit and follow up
care)
The plan would be responsible for the other costs of these EXAMPLE covered services.
Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For assistance, please call 866-393-0002.
Smartphone or Tablet
To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.
Non-Discrimination
Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color,
national origin, sex, age, disability, gender identity or sexual orientation.
We provide free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the
Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: P.O. Box 24030, Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates
(Aetna).
TTY: 711
Language Assistance:
To access language services at no cost to you, call 1-888-982-3862.
Albanian -
Për shërbime përkthimi falas për ju, telefononi 1-888-982-3862.
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88982-386
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̀
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Kurdish -
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Laotian -
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Marshallese -
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Micronesian-
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de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke cɔl kɔc ye kɔc kuɔny ne nɔmba 1-888-982-3862.
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Telugu -
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้
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Urdu -
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