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Floyd County Productions
Effective Date: 08-01-2017
Aetna Health Network Option
SM
- Georgia
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA HEALTH INC. AND AETNA HEALTH INSURANCE COMPANY - FULL RISK
Outpatient Speech Therapy
$50 copay; deductible waived
40%; after deductible
Limited to 20 visits; per calendar year
Outpatient Physical and
Occupational Therapy
$50 copay; deductible waived
40%; after deductible
Limited to 30 visits; per calendar year
Spinal Manipulation Therapy
$50 copay; deductible waived
40%; after deductible
Limited to 20 visits; per calendar year
Autism Behavioral Therapy
Refer to MBH Outpatient Mental
Health
Refer to MBH Outpatient Mental
Health
Covered same as any other Outpatient Mental Health benefit
Autism Applied Behavior Analysis
Refer to MBH Outpatient Mental
Health
Refer to MBH Outpatient Mental
Health
Covered same as any other Outpatient Mental Health benefit with no age or visit limitations.
Autism Physical Therapy
$50 copay; deductible waived
40%; after deductible
Covered to age 7, unlimited visits.
Autism Occupational Therapy
$50 copay; deductible waived
40%; after deductible
Covered to age 7, unlimited visits.
Autism Speech Therapy
$50 copay; deductible waived
40%; after deductible
Covered to age 7, unlimited visits.
Durable Medical Equipment
50%; after deductible
50%; after deductible (must precertify
if over $1,500)
Diabetic Supplies
Pharmacy cost sharing applies if
Pharmacy coverage is included;
otherwise PCP office visit cost
sharing applies.
Pharmacy cost sharing applies if
Pharmacy coverage is included;
otherwise PCP office visit cost
sharing applies.
Women's Contraceptive drugs and
devices not obtainable at a
pharmacy
Covered 100%; deductible waived
Covered same as any other medical
expense.
Affordable Care Act mandated
Women's Contraceptives
Covered 100%; deductible waived
Covered same as any other expense.
Transplants
20%; after deductible
40% per admission; after deductible
Preferred coverage is provided at an
IOE contracted facility only.
Non-Preferred coverage is provided
at a Non-IOE facility.
FAMILY PLANNING
IN-NETWORK
OUT-OF-NETWORK
Infertility Treatment
Your cost sharing is based on the
type of service and where it is
performed
Your cost sharing is based on the
type of service and where it is
performed
Diagnosis and treatment of the underlying medical condition only.
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