Aetna HMO Plan


2009 Benefits Open Enrollment

Aetna HMO
Benefit Summary

This plan is available to you if you are a non U.S.-citizen on a J-1 Visa

In an HMO Plan, the primary care physician manages all health care. The selection of a primary care physician and hospital is limited to those affiliated with the HMO. Health care is only covered when provided by the HMO or when permission is received for emergency care elsewhere. No claim forms are required. No pre-existing condition exclusion applies.

For a current Physician Directory, visit Aetna HMO's Web site at http://www.aetnanavigator.com and select "Aetna Standard Plans/HMO**".

For more information about these plan benefits or details on services not listed, call Aetna HMO's Customer Service Department toll free at 1-888-287-4296.

The chart below provides a brief overview of the benefits offered. Please review the Aetna HMO Plan package for more details, or call the Office of Human Resources at 609-258-3302.

Plan Provision	You Pay
Deductible The amount you pay each year before the plan begins covering particular medical expenses.	None
Coinsurance (Out-of-pocket expense) The percentage of medical expenses shared by you and the plan after you meet your deductible.	Not applicable
Coinsurance Limit (Maximum out-of-pocket expense) Total amount you pay out-of-pocket in one calendar year before the plan pays 100% of your medical expenses. (Includes your deductible and coinsurance, but excludes copayments).	Not applicable
Lifetime Maximum Medical/Surgical/Mental Health	Not applicable
Feature/Service	You Pay
Physician Services Performed in an Office Setting Office visits for routine care; diagnosis and treatment of an illness or injury.	$15 copay per primary care physician office visit $20 copay per specialist visit
Preventive Care Preventive physicals, well-child care (including scheduled immunizations), PSA, PAP tests and well woman care office visits.	$15 copay per primary care physician office visit $20 copay per specialist visit
Office Visits for Maternity Care	$20 copay for 1st office visit only
Inpatient Hospital Services Medical/Surgical Care (includes maternity).	$0
Emergency Room Care Services administered for conditions meeting the definition of an emergency. You must follow the instructions on your member ID card.	$50 copayment per emergency visit for all medically necessary treatment. Waived if admitted.
Surgery (Inpatient/Outpatient) Anesthesia and use of an operating room or related facility in a hospital or authorized institution.	$0
Outpatient Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification. 50 visits per year.	$20 copay per office visit
Inpatient Mental Health and Substance Abuse 35 days per calendar year limit at approved facilities only.	$0
Substance Abuse Detoxification	$0
Outpatient Physical Rehabilitation Short-term physical, speech, occupational, or pulmonary and cardio rehabilitation therapies. Maximum of 50 visits per therapy, per calendar year.	$20 copay per office visit
Chiropractic 20 visits per calendar year	$20 copay per office visit
Nutritional Counseling Limited to 3 visits per calendar year with referral and/or script by your physician; copay will apply	$15 copay per primary care physician office visit $20 copay per specialist visit
Hearing Exam 1 exam per calendar year; copay will apply	$15 copay per primary care physician office visit $20 copay per specialist visit
Hearing Aids Maximum reimbursement of $1,500 every three years	Covered
Routine Annual Eye Exam	$20 copay
Prescription Glasses or Contact Lenses	$70 reimbursement every 2 years, plus discounts at participating providers

Prescription Drug Program - Medco Health

Retail Program (30 day supply)	Mail Order Program (90 day supply)
$5 Copay - Generic drugs $20 Copay - Brand Name drugs $35 Copay - Multi Source drugs*	$10 Copay - Generic drugs $40 Copay - Brand Name drugs $70 Copay - Multi Source drugs*
Deductible: NONE

*Multi Source drugs are Brand Name Drugs for which generics are available. You will pay this copay if you receive the Brand Name.

Aetna HMO Member Information You should receive your Aetna HMO ID card at the end of December 2008. Aetna provides a "family" ID card. Rather than each Aetna member receiving an ID card, the "family" will receive two cards with all of the members information listed on them. The ID card should be used to access medical care. If a doctor's office or hospital needs to verify coverage, they can call the Office of Human Resources 609-258-3302 or you may provide them with the following information:

Plan:	Aetna HMO
Group number:	3015
Member number:	Will be system generated
Phone number:	1-800-287-4296

You will receive a separate ID card for the prescription drug program administered through Medco Health. If you need to purchase a prescription at a participating retail pharmacy before you receive your ID card, please provide the pharmacist with the following information:

Your Provider:	Medco Health
Member Number:	Will be system generated
Phone number:	1-800-711-0917

If you do not appear in the system yet, you should pay for your prescription, submit the receipt along with the Medco claim form to Medco Health. The claim form can be obtained from the web at www.princeton.edu/hr or by calling the Office of Human Resources at 609-258-3302.