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Aetna Choice POS II (POS) Summary of Benefits

WHAT YOU PAY IN-NETWORK

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 Chiropractic Care $15 copay $25 copay No copay $25 copay $0 $0 N/A N/A

WHAT YOU PAY OUT-OF-NETWORK

$250 $500 $3,000 $6,000 Unlimited 20% after deductible 20% after deductible 20% after deductible 20% after deductible

$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

No Coverage 20% after deductible 20% after deductible

20% after deductible No Coverage 20% after deductible 20% after deductible $50 copay (waived if admitted) $50 copay (waived if admitted) $20 copay plus 20% after deductible

$25 copay No copay

20% after deductible 20% after deductible

Not covered by Aetna. Covered under APS Healthcare. Refer to State Employee Benefits Guide for Information.

No copay No copay

No copay No copay

20% after deductible 20% after deductible 20% after deductible 20% after deductible

Acupuncture for Chronic Pain

Durable Medical Equipment Diabetic Supplies

*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.

Information

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