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Open Access Aetna Select (EPO) Summary of Benefits


Deductible Single Family Coinsurance Limit Single Family Lifetime Maximum Benefit Primary Care Physician Visits Office Visits Specialty Care Office Visits Diagnostic Lab and X-rays Physical, Occupational, Speech Therapy Preventive Care Routine Physicals Mammogram Routine Eye Exam (any licensed vision care provider) Routine Ob/Gyn Exam Well-Child Care 0­21 years Outpatient Surgery Hospitalization Emergency Treatment Emergency Hospital Charges* Emergency Physician Services* Urgent Care Centers Maternity First Ob/Gyn Visit & Hospital st 1 Ob/Gyn visit Hospital/Global Maternity Charge Behavioral Health Inpatient Outpatient Chiropractic Care Acupuncture for Chronic Pain Durable Medical Equipment Diabetic Supplies $0 $0 N/A N/A Unlimited $15 copay $25 copay No copay $25 copay $0 No copay Aetna pays up to $45; member responsible for balance No copay No copay No copay No copay $50 copay (waived if admitted) $50 copay (waived if admitted) $20 copay

$25 copay No copay 100% up to 365 days $15 copay No copay No copay No copay No copay

*A penalty applies for non-emergency use of emergency hospital services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage.



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