Crawford & Company
Aetna Select
BENEFIT HIGHLIGHTS
Plan Benefits
Primary Care Physician (PCP) Office Visit
Preventive Care
Well Child Care/Immunizations
Periodic Physical Exams (Children and Adults)
7 Exams per first 12 Months of life
2 Exams 13-24 Months of life
1 Exam per 12 Months thereafter to age 18
1 Exam per Adult ages 18-65 and over
$15 co-payment per office visit
Routine Mammograms
Baseline Mammogram for covered females 35-40
Annual Mammograms for covered Females ages 40 and over
Routine Gynecologiclal Exams(includes pap and related lab fees)
Routine PSA/Digital Rectal Exam
Annual test for covered Males age 40 and over
Specialty Physician Office Visit
Office Visits
Consultant and Referral Physician Services
Allergy Treatment/Injections
100%
Allergy Serum (dispensed by physician in office)
Surgery Performed in the Physician’s Office
Second Opinions
Outpatient Preadmission Testing
Office Visit-Primary Care Physician or Specialty Physician
Outpatient Facility
Independent X-ray and/or Lab Facility
Surgery performed in PCP/Specialist office
Inpatient Hospital Services – includes
Semi-Private Room and Board
Diagnostic/Therapeutic Lab and X-ray
Drugs and Medication
Operating and Recovery Room
Radiation Therapy and Chemotherapy
Anesthesia and Inhalation Therapy
Inpatient Hospital Doctor’s Visits/Consultations
Inpatient Hospital Professional Services
Outpatient Facility Services
Operating Room, Recovery Room, Procedure Room and Treatment
Room including:
Diagnostic/Therapeutic Lab and X-rays
Anesthesia and Inhalation Therapy
Physician and Outpatient Professional Services
Laboratory and Radiology Services
MRIs, CAT Scans and PET Scans
Other Laboratory and Radiology Services
Outpatient Hospital Facility
Independent X-Ray and/or Lab Facility
Short-Term Rehabilitative Therapy and Chiropractic Services
(includes cardiac rehab, physical, speech, occupational and
chiropractic therapy)
Unlimited visits/days maximum per contract year for all therapies
combined
Prescription Drugs
Emergency and Urgent Care Services
Physician’s Office – PCP or Specialty Physician
Hospital Emergency Room
Participating Urgent Care Facility or Outpatient Facility
Ambulance
Inpatient Services at Other Health Care Facilities
Skilled Nursing, Rehabilitation and Sub-Acute Facilities
60 days combined maximum per contract year
$15 co-payment per office visit
$15 co-payment per office visit
$25 co-payment
No charge; $15 co-payment per office visit for associated wellness exam
$25 co-payment per office visit
$25 co-payment per office visit
$15 or $25 depending on PCP or Specialist renders care, or actual charge
per office visit, whichever is less
No charge
$25 co-payment per office visit
$25 co-payment per office visit
$15 or $25 co-payment per office visit
90% of eligible charges
90% of eligible charges
Covered at applicable copay - $15 or $25 co-payment
$150 co-payment per day (up to 3 co-payments per admission) then plan
pays 90% of eligible charges (co-payment waived if readmitted within 30
days)
90% of eligible charges
90% of eligible charges
$100 co-payment per facility visit, then the plan pays 90% of eligible charges
90% of eligible charges
90% of eligible charges
90% of eligible chares
90% of eligible charges
$25 co-payment per office visit
Provided through Express Scripts
$15 or $25 co-payment per office visit
$100 co-payment per visit (co-pay waived if admitted)
$50 co-payment per visit (co-pay waived if admitted)
90% of eligible charges
90% of eligible charges
BENEFIT HIGHLIGHTS
Maternity Care Services
Initial Office Visit to Confirm Pregnancy
All subsequent Prenatal Visits, Postnatal Visits and Physician's
Delivery Charges
Inpatient Hospital/Birthing Center Charges
Home Health Services
Unlimited days per contract year; 16 hour maximum per day
Family Planning Services
Office Visits (tests, counseling)
Vasectomy/Tubal Ligation (excludes reversals)
Outpatient Facility
Physician’s Services
Infertility Services
Office Visit (tests, counseling)-Specialty Physician
Diagnosis/Treatment of Underlying medical condition only (excludes
artificial insemination, in-vitro fertilization, GIFT, ZIFT, etc.)
Oral Surgery – Covered procedures include: Gingevectomy or
Gingivoplasty, Osseous Surgery, Removal of Impacted Tooth, Surgical
removal of residual tooth roots and Ora-Antral Fistula Closure
TMJ - Surgical and Non-Surgical – Covers medical in nature
treatment only, including exams, x-rays, injections, anesthetics,
physical therapy and oral surgery; excludes appliance therapy and tooth
reconstruction.
Physician’s Office
Plan Benefits
$25 co-payment for initial office visit
90% of eligible charges
$150 co-payment per day (up to 3 co-payments per admission) then Plan
pays 90% of eligible charges
No charge
$25 co-payment per office visit
$100 co-payment per facility visit, then plan pays 90% of eligible charges
90% of eligible charges
$25 co-payment per office visit
100% after $25 copay
$25 co-payment per office visit
Lifetime Maximum Benefit (Surgical only)
Mental Health Services
Inpatient - 30 days maximum per contract year
$15,000
Outpatient - 50 visits maximum per calendar year
$10 co-payment per visit: Visits 1-10
$20 co-payment per visit: Visits 11-50
Substance Abuse Treatment
Inpatient - 30 days maximum per contract year
$25 co-payment per day, plan pays 90% of eligible charges
$25 co-payment per day, then plan pays 100% of charges
Outpatient -60 visits maximum per calendar year
$10 co-payment per visit: Visits 1-10
$20 co-payment per visit: Visits 11-60
Hospice Care in and out patient
Home Health Care
Durable Medical Equipment
100%
100%
Vision Care
Eye Exam one every 24 months
Eye Glasses/Contact Lenses are not covered
After $200 annual deductible, plan pays 100% of eligible charges
$25.00 co-payment per office visit
OTHER BENEFIT INFORMATION
Annual Deductible
Individual
Family
Annual Out-of-Pocket (OOP) Maximum
Individual
Family (Excludes co-payments)
Coinsurance
Lifetime Maximum
Pre-existing Condition Limitation
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None
None
$1500
$3000
90% of eligible charges. You pay 10% of eligible charges
$1,000.000. $10,000 automatic yearly restoration
Yes
All services, except for emergency services, routine care provided by a participating OB/GYN, and Mental Health and Substance
Abuse services authorized by Aetna Behavioral Health, must be provided by or authorized by your Primary Care Physician (PCP) in
order to be covered.
Deductibles and co-payments do not apply to the out-of-pocket maximums. Only your 10% co-insurance applies to the out-of-pocket
maximum. This coinsurance is no longer required once the out-of-pocket maximum is reached, however any applicable copayments
will continue to apply to covered services.
Child dependent coverage eligible from birth to age 19 or up to age 25 if a full-time student.
Excludes children of unmarried minor dependents not residing with employee.
Pre-certification is responsibility of provider.
This plan imposes a pre-existing condition exclusion. The pre-existing condition exclusion means that if you have a medical
condition before coming to this plan, you may have to wait a certain period of time before the plan will provide coverage for that
condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or
received or for which the individual took prescribed drugs within 90 days. If you had prior creditable coverage within 90 days
immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be
waived. If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior
coverage or because there was more than a 90 day gap from the date your prior coverage terminated to your enrollment date), we will
apply your plan’s pre-existing conditions exclusion. In order to possibly eliminate your exclusion period based on your creditable
coverage, you should provide us a copy of any certificates of creditable coverage you have. Please contact Aetna Member Services
at 1-888-282-4172 if you need assistance in obtaining a certificate of creditable coverage from your prior carrier of if you have any
questions on the information noted above. The pre-existing condition exclusion does not apply to pregnancy nor to a child who is
enrolled in the plan within 31 days of birth, adoption, or placement for adoption.
These summaries are only a general description of your benefits. Should there be a conflict between the
benefits shown on the chart and those in the legal plan documents, the terms of the plan documents will be
used to determine coverage and benefits