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Floyd County Productions
Effective Date: 08-01-2017
Aetna Health Network Option
SM
- Georgia
Qualified High Deductible Health Plan
GA 17 HNOption HSA 5000 100/70 EMB RX14.25
PLAN DESIGN & BENEFITS
PROVIDED BY AETNA HEALTH INC. AND AETNA HEALTH INSURANCE COMPANY - FULL RISK
Outpatient Short-Term
Rehabilitation
Covered 100%; after deductible
30% per visit; after deductible
Limited to 20 visits; per calendar year
Includes Speech, Physical, and Occupational therapy
Spinal Manipulation Therapy
Covered 100%; after deductible
30%; 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
Covered 100%; after deductible
30%; after deductible
Covered to age 7, unlimited visits.
Autism Occupational Therapy
Covered 100%; after deductible
30%; after deductible
Covered to age 7, unlimited visits.
Autism Speech Therapy
Covered 100%; after deductible
30%; after deductible
Covered to age 7, unlimited visits.
Durable Medical Equipment
Covered 100%; after deductible
30%; 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
Covered 100%; after deductible
30% per admission; after deductible
Preferred coverage is provided at an
IOE contracted facility only.
Non-Preferred coverage is provided
at a Non-IOE facility.
Bariatric Surgery
Not Covered
Not Covered
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.
Comprehensive Infertility Services
Not Covered
Not Covered
Advanced Reproductive
Technology (ART)
Not Covered
Not Covered
In-vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved
embryo transfers, intracytoplasmic sperm injection (ICSI), or ovum microsurgery
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