Summary of Benefits Carilion Choice POS II

Plan Design & Benefits
Administered by Aetna Life Insurance Company - Self Funded

Washington and Lee University
Effective Date: 07-01-2024
Aetna Choice® POS II -- ASC
CARILION NETWORK

PLAN FEATURES IN-NETWORK OUT-OF-NETWORK

Benefit limitations - Some service or supplies have limits on them per year. There might be a maximum number of visits or days, or a dollar limit per year. In such cases, the benefit year begins on the day your plan coverage takes effect (unless otherwise noted). Refer to your plan documents to learn more.

Deductible (per plan year)
Covered expenses in-network add up towards your in-network deductible. Covered expenses out-of-network add up towards your out-of-network deductible.
You must first meet the deductible before the plan begins paying benefits, unless otherwise noted. The amount you pay (cost sharing) for some medical services does not count toward your deductible. Prescription drug costs do not count toward the deductible. Refer to your plan documents for details.
Your family will have one deductible. You will meet it when the expenses of several family members add up to the family deductible. No one person will have to pay more than the individual deductible.

 $750 per Individual
$1,500 per Family		 $1,000 per Individual
$2,000 per Family

Member coinsurance
Applies to all expenses except as noted.

 You pay 10% You pay 20%

Out-of-pocket limit (per plan year)
Covered expenses in-network add up towards your in-network out-of-pocket limit. Covered expenses out-of-network add up towards your out-of-network out-of-pocket limit.
Some of your cost sharing may not count toward the out-of-pocket limit.
Your pharmacy expenses count toward your out-of-pocket limit.
In-network expenses include coinsurance/copays and deductibles.
Out-of-network expenses include coinsurance and deductibles. Penalty amounts do not apply.
Your family will have one out-of-pocket limit. You will meet it when the expenses of several family members add up to the family out-of-pocket limit. No one person will have to pay more than the individual out-of-pocket limit amount.

 $3,000 per Individual
$6,000 per Family		 $3,250 per Individual
$6,500 per Family

Lifetime maximum
Unlimited except where otherwise indicated.

Payment for out-of-network care**

 Does not apply Professional: Prevailing Charges
Facility: Facility Charge Review

Primary care physician selection

 Encouraged Does not apply

Precertification requirements
Some out-of-network services need approval by us in advance (precertification). Without this approval, we reduce benefits by $400. Refer to your plan documents for a full list of services that need this approval.

Referral requirement

 Not required None

Telehealth consultations
You can access covered services for telehealth visits from different kinds of providers in your plan. Log on to Aetna.com to see a list of telehealth providers. You'll also find more about your options, including cost share amounts.

Network Designations
In order to be covered at the preferred in-network benefit level you must use a designated provider for care. If you receive care from a non-designated provider your care may be paid at the out-of-network benefit level or may not be covered at all.
benefit level or may not be covered at all.
PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK
Routine adult physical exams/immunizations
1 exam every 12 months until age 65, then 1 exam every 12 months age 65 and older		 Covered 100%; no deductible 20%; after deductible

Routine well child exams/immunizations

  • 7 exams in the first 12 months
  • 3 exams from age 13 to 24 months
  • 3 exams from age 25 to 36 months
  • 1 exam every 12 months thereafter until age 22
 Covered 100%; no deductible 20%; after deductible

Routine gynecological care exams
1 exam and pap smear per year, includes related fees.

 Covered 100%; no deductible 20%; after deductible

Routine mammogram
Recommended: 1 per calendar year age 40 and over

 Covered 100%; no deductible 20%; after deductible

Women's health
Includes: Screening for gestational diabetes, HPV (Human- Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for human immunodeficiency virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies and counseling.
Also includes: contraceptive methods (ACA mandated contraceptives, including contraceptives and devices you can't get at a pharmacy), sterilization procedures (including tubal ligation), patient education and counseling. Limits may apply.

 Covered 100%; no deductible 20%; after deductible

Pre-natal maternity

 Covered 100%; no deductible 20%; after deductible

Routine digital rectal exam
1 exam per calendar year age 40 and over

 Covered 100%; no deductible 20%; after deductible

Prostate-specific antigen test
1 exam per calendar year age 40 and over

 Covered 100%; no deductible 20%; after deductible

Colorectal cancer screening
Recommended: For members age 45 and over

 Covered 100%; no deductible 20%; after deductible

Routine eye exams
1 routine exam per 12 months

 Covered 100%; no deductible 20%; after deductible

Routine hearing screening

 Covered 100%; no deductible 20%; after deductible

Medications

 Certain over-the-counter preventive medications covered 100% in network Certain over-the-counter preventive medications covered 100% in network
PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK
Office visits to primary care physician (PCP)
Includes services of an internist, general physician, family practitioner or pediatrician.		 $5 office visit copay; no deductible 20%; after deductible
Telehealth consultation with non-specialist $5 office visit copay; no deductible 20%; after deductible
Specialist office visits $50 office visit copay; no deductible 20%; after deductible
Telehealth consultation with specialist $50 office visit copay; no deductible 20%; after deductible
Hearing exams
1 routine exam per 24 months		 $50 copay; no deductible 20%; after deductible
Walk-in clinics
Walk-in clinics are free-standing health care facilities. Sometimes they may be within a pharmacy, drug store, supermarket, or other retail store. They offer some limited medical care and services.
Not walk-in clinics: Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers, and physician offices.
 $30 copay; no deductible
Designated Walk-in clinics
Covered 100%; no deductible		 20%; after deductible
Telehealth consultations for non-emergency services through a walk-in clinic
We pay telehealth screenings and counseling services from walk-in clinic as a preventive care benefit.		 Your cost sharing amount depends on the type of service and where you receive it.
Designated Walk-in clinics
Covered 100%; no deductible		 20%; after deductible
Allergy testing Your cost sharing amount depends on the type of service and where you receive it. Your cost sharing amount depends on the type of service and where you receive it.
Allergy injections Your cost sharing amount depends on the type of service and where you receive it. Covered 100% when an office visit charge is not applicable. Your cost sharing amount depends on the type of service and where you receive it.
DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK
Diagnostic X-ray (Other than complex imaging services)
When your physician performs and bills for this service at their office, you pay your office visit cost share amount.		 $20 copay; no deductible 20%; after deductible
Diagnostic laboratory
When your physician performs and bills for this service at their office, you pay your office visit cost share amount.		 10%; after deductible 20%; after deductible

Diagnostic complex imaging
When your physician performs and bills for this service at their office, you pay your office visit cost share amount.

 $100 copay; no deductible 20%; after deductible
EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK
Urgent care provider $50 office visit copay; no deductible 20%; after deductible
Non-urgent use of urgent care provider Not covered Not covered
Emergency room
Copay waived if admitted		 $300 copay; no deductible Same as in-network care
Non-emergency care in an emergency room Not covered Not covered
Emergency use of ambulance $300 copay; no deductible Same as in-network care
Non-emergency use of ambulance Not covered Not covered
HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK
Inpatient coverage
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.		 $500 copay; no deductible 20%; after deductible
Inpatient maternity coverage (includes delivery and postpartum care)
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.		 $500 copay; no deductible 20%; after deductible
Outpatient hospital
When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.		 10%; after deductible 20%; after deductible
Outpatient surgery - hospital
When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.		 $300 copay; no deductible 20%; after deductible
Outpatient surgery - freestanding facility
When you receive outpatient care at a hospital but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.		 $300 copay; no deductible 20%; after deductible
MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK
Inpatient
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive		 $500 copay; no deductible 20%; after deductible
Mental health office visits $25 copay; no deductible 20%; after deductible
Mental health telehealth consultations $25 office visit copay; no deductible 20%; after deductible
Other mental health services
When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.		 Covered 100%; no deductible 20%; after deductible
SUBSTANCE ABUSE IN-NETWORK OUT-OF-NETWORK
Inpatient
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.		 $500 copay; no deductible 20%; after deductible
Residential treatment facility
When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.		 $500 copay; no deductible 20%; after deductible
Substance abuse office visits $25 copay; no deductible 20%; after deductible
Substance abuse telehealth consultations $25 office visit copay; no deductible 20%; after deductible
Other substance abuse services
When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.		 Covered 100%; no deductible 20%; after deductible
THERAPY SERVICES IN-NETWORK OUT-OF-NETWORK
Spinal manipulation therapy
Limited to 30 visits per year		 $50 copay; no deductible 20%; after deductible
Outpatient rehabilitative physical and occupational therapy $50 copay; no deductible 20%; after deductible
Outpatient rehabilitative speech therapy $50 copay; no deductible 20%; after deductible
Habilitative physical therapy Covered 100%; no deductible 20%; after deductible
Habilitative occupational therapy Covered 100%; no deductible 20%; after deductible
Habilitative speech therapy Covered 100%; no deductible 20%; after deductible
Autism related physical therapy Covered 100%; no deductible 20%; after deductible
Autism related occupational therapy Covered 100%; no deductible 20%; after deductible
Autism related speech therapy Covered 100%; no deductible 20%; after deductible
Autism related behavioral therapy
These benefits are combined with outpatient mental health visits		 $25 copay; no deductible 20%; after deductible
Autism related applied behavior analysis
Your benefits for these services are the same as any other outpatient mental health other services benefit		 Covered 100%; no deductible 20%; after deductible
OTHER SERVICES IN-NETWORK OUT-OF-NETWORK
Skilled nursing facility
Limited to 100 days per year
When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.		 10%; after deductible 20%; after deductible
Home health care
Limited to 100 visits per year
Private duty nursing not included.
Limited to three visits per day by staff from a home health care agency. One visit equals a period of four hours or less.		 10%; after deductible 20%; after deductible
Hospice care - inpatient
When you're admitted into a facility for the care you need, your cost sharing amount counts toward all covered benefits you receive.
 Covered 100%; after deductible 20%; after deductible
Hospice care - outpatient
When you receive outpatient care at a facility but don't stay overnight, your cost sharing amount counts toward all covered benefits during your visit.		 Covered 100%; after deductible 20%; after deductible
Private duty nursing
Limited to 20 eight hour shifts per year.
We count each period of up to 8 hours as one private duty nursing shift.		 10%; after deductible 20%; after deductible
Durable medical equipment 10%; after deductible 20%; after deductible
Hearing aids
Limited up to $3,000 lifetime maximum		 50%; after deductible 50%;after deductible
Diabetic supplies (if not covered under the prescription drug benefit) Covered same as any other medical
expense.
You pay your prescription drug cost sharing amount if you have prescription drug coverage. If not, you pay your PCP visit cost sharing amount.		 Covered same as any other medical
expense.
You pay your prescription drug cost sharing amount if you have prescription drug coverage. If not, you pay your PCP visit cost sharing amount.
Infusion therapy - home/office $50 copay; no deductible 20%; after deductible
Infusion therapy - outpatient hospital/freestanding facility Your cost sharing amount depends
on the type of service and where you
receive it.		 Your cost sharing amount depends
on the type of service and where you
receive it.
Gene-based, Cellular, and other
Innovative Therapies (GCITTM)		 Your cost sharing amount depends
on the type of service and where you
receive it.
$50 copay; no deductible for gene
therapy drugs, if applicable
In-network coverage is provided at
GCITTM designated facilities only.		 Not covered
Vision eyewear Covered 100% up to $150 every 12 months; not subject to any plan deductible, if applicable  Covered 100% up to $150 every 12 months; not subject to any plan deductible, if applicable
Transplants $500 copay; no deductible
In-network coverage is only available at Institutes of Excellence (IOE) contracted facility.		 20%; after deductible
Out-of-network coverage applies when you use a non-IOE facility. You will pay more out-of-pocket when using a non-IOE facility.
Bariatric surgery
When you're admitted into a hospital for the care you need, your cost sharing amount counts toward all covered benefits you receive.		 $500 per admission copay; no
deductible		 Not covered
Acupuncture
Limited to 10 visits per year		 $25 copay; no deductible 20%; after deductible
FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK
Infertility treatment
You have coverage for the diagnosis and treatment of the underlying cause of infertility.		 Your cost sharing amount depends on the type of service and where you receive it. Your cost sharing amount depends on the type of service and where you receive it.
Comprehensive infertility services
Coverage includes artificial insemination and ovulation induction limited to 2 courses of treatment per member lifetime. Lifetime maximum applies to all procedures covered by any of our plans except where prohibited by law.		 10%; after deductible 20%; after deductible
Advanced Reproductive Technology (ART)
ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Limited to 2 courses of treatment per member's lifetime. Maximum applies to all procedures covered by any of our plans except where prohibited by law.		 10%; after deductible 20%; after deductible
Vasectomy Covered 100%; no deductible 20%; after deductible
Tubal ligation Covered 100%; no deductible 20%; after deductible
Pharmacy plan type None None

GENERAL PROVISIONS

Dependents who are eligible to be on your plan
Spouse, children from birth to age 26. Student status of children does not matter.

**We cover the cost of services based on whether doctors are "in-network" or "out-of-network." We want to help you understand how much we pay for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this "out-of-network" care.
You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out-of-network, your health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital.

When you choose out-of-network care, we limit the amount it will pay. This limit is called the "recognized" or "allowed" amount.
This amount is based on the out-of-network plan you or your employer picks.

  • For doctors and other professionals the amount is based on the "prevailing" charges. We get this data from an external database.
  • For hospitals and other facilities, the amount is based on the Facility Fee Schedule.

Your doctor sets his or her own rate to charge you. It may be higher -- sometimes much higher -- than what your plan "recognizes." Your doctor may bill you for the dollar amount that we don't "recognize." You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the "recognized charge" counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit our website.
You can avoid these extra costs by getting your care from Aetna's broad network of health care providers. Go to www.aetna.com and click on "Find a Doctor" on the left side of the page. If you are already a member, sign on to your Navigator member site.
This applies when you choose to get care out-of-network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in-network. You pay cost sharing and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles.
This way of paying out-of-network doctors and hospitals applies when you choose to get care out-of-network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in-network. You pay your plan's copayments and deductibles for your in-network level of benefits. Contact us if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments and deductibles.

Plans are provided by: Aetna Health Inc. While this material is believed to be accurate as of the production date, it is subject to change.

Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered.

See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services.

The following is a list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer.

  • All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents.
  • Cosmetic surgery, including breast reduction.
  • Custodial care.
  • Dental care and dental X-rays.
  • Donor egg retrieval
  • Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial.
  • Hearing aids
  • Home births
  • Immunizations for travel or work, except where medically necessary or indicated.
  • Implantable drugs and certain injectable drugs including injectable infertility drugs.
  • Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents.
  • Long-term rehabilitation therapy.
  • Non-medically necessary services or supplies.
  • Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and over- the-counter medications (except as provided in a hospital) and supplies.
  • Radial keratotomy or related procedures.
  • Reversal of sterilization.
  • Services for the treatment of sexual dysfunction/enhancement, including therapy, supplies or counseling or prescription drugs.
  • Special duty nursing.
  • Therapy or rehabilitation other than those listed as covered.
  • Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions.

In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

Translation of this material into another language may be available. Please call Member Services at the number on the back of your ID card.

Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al 1-888-982-3862.

Plan features and availability may vary by location and group size.

For more information about Aetna plans, refer to www.aetna.com.

Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family.