Medicare 25 Open Plan Rx Group Plan C1 PLAN ... - Aetna Medicare

Retirees of EMBARQAetna Medicare Open SM Plan (PFFS)Medicare 25 Open PlanRx Group Plan C1National Service Area including Puerto RicoPLAN DESIGN AND BENEFITSPROVIDED BY AETNA LIFE INSURANCE COMPANY INCSpecialist Office Visits$25 copayAllergy Testing/Treatment$25 copayFor initial testing by a specialist; with or without physician encounterDIAGNOSTIC PROCEDURESCost ShareDiagnostic Laboratory and X-Ray$25 copayEMERGENCY MEDICAL CARECost ShareUrgent Care Provider$25 copayEmergency Room; Worldwide (waived if admitted) $50 copayAmbulance$25 copayHOSPITAL CARECost ShareInpatient Coverage$250 copayThe member cost sharing applies to covered benefits incurred during a member's inpatient stay.Outpatient SurgeryCovered 100%The member cost sharing applies to covered benefits incurred during a member's outpatient visit.MENTAL HEALTH SERVICESInpatient Mental Illness$250 copayThe member cost sharing applies to covered benefits incurred during a member's inpatient stay.Outpatient Mental Illness$25 copayThe member cost sharing applies to covered benefits incurred during a member's outpatient visit.ALCOHOL/DRUG ABUSE SERVICESInpatient Substance Abuse (Detox and Rehab)$250 copayThe member cost sharing applies to all covered benefits incurred during a member's inpatient stay.Outpatient Substance Abuse (Detox and Rehab) $25 copayThe member cost sharing applies to covered benefits incurred during a member's outpatient visit.OTHER SERVICESSkilled Nursing Facility(100 days per Medicare benefit period)The member cost sharing applies to covered benefits incurred during a member's inpatient stay.Home Health CareCovered 100%Hospice CareCovered by Medicare at a Medicare certified hospiceOutpatient Short-Term Therapy (speech, physical, cardiac $25 copayand occupational)Chiropractic Care$25 copayFor manual manipulation of the spine to the extent covered by MedicareDurable Medical Equipment/Prosthetic Devices 20%H5736_7F_70614Cost Share$0 per day - days 1-10$25 per day - days 11-20$50 per day - days 21-100Prepared: 11/17/20093:24 PM Page 2