HSA PPO

With the HSA PPO plan, you receive full coverage for in-network preventive care and have the same Aetna Choice POS II network of doctors as the Traditional PPO plan. There are no co-pays and you must meet the annual deductible before the plan begins to pay benefits. You may enroll in a Health Savings Account (HSA) which comes with quarterly employer funding. You can use your HSA to cover your out-of-pocket costs including the annual deductible and coinsurance. For HSA eligibility, please refer to the Health Savings Account (HSA) page.

You may also enroll in a Limited Purpose Flexible Spending Account (LPFSA) for your out-of-pocket dental and vision expenses.

The HSA PPO plan gives you the option to visit any provider, allowing you to shop around when you need healthcare. You can visit any doctor or facility, but you will receive the best value when you go in-network. To find in-network providers, visit Aetna’s Doc Find. (Use the Aetna Choice POS II network.)

HSA PPO Plan Details

In-Network1 Out-of-Network1
VMware Funding per Quarter2 Individual: $187.50
Family: $375
Individual: $187.50
Family: $375
Annual Deductible Individual: $1,500
Family: $3,000
Individual: $1,500
Family: $3,000
Annual Out-of-Pocket (OOP) Maximum3 Individual: $2,500
Family: $5,000
Individual: $6,000
Family: $12,000
Employee Coinsurance 10% after deductible 30% of UCR4, after deductible
Preventive (Annual Physicals, Well Care Exams) 100% covered, not subject to deductible 30% of UCR4, after deductible
Physician Visits 10% after deductible 30% of UCR4, after deductible
Lab and X-Ray 10% after deductible 30% of UCR4, after deductible
Emergency Room 10% after deductible 10% of UCR5,after deductible
Ambulance 10% after deductible 30% of UCR4, after deductible
Hospitalization 10% after deductible 30% of UCR4, after deductible
Chiropractic 10% after deductible
Up to 20 visits per year
30% after deductible
Up to 20 visits per year
Acupuncture 10% after deductible
Up to 12 visits per year
30% after deductible
Up to 12 visits per year
Physical Therapy 10% after deductible 30% after deductible 
Speech Therapy5 10% after deductible 30% after deductible 
Infertility/Fertility Preservation 50% after deductible up to $10,000 lifetime max ($7,000/$3,000 for med/Rx) Not Covered

1 Individual deductible and OOP maximum only apply to employees enrolled in employee-only tier. Members in dependent tiers must satisfy the family deductibles and OOP maximums. Paid Interns are only eligible to enroll in the HSA PPO plan.
2 VMware funding based on coverage at the end of each quarter. Must be active on the last day of the quarter. Paid Interns are not eligible for VMware funding. HealthEquity accounts funded the pay period following the close of quarter.
3 OOP maximum includes Prescription Rx.
4 Usual, customary and reasonable charges.
5 Available to those with conditions of medical necessity.

Prescription Rx

Coverage for prescription drugs is included when you enroll in the HSA PPO plan. The HSA PPO plan has a combined deductible which means that you must must meet the annual deductible before the plan pays benefits for prescription drugs. However, you may use your HSA to cover the cost of prescription drugs. In general, generic and brand name prescriptions filled at a retail pharmacy are limited to a 30-day supply. Prescriptions filled through the mail-order program may be up to a 90-day supply.

Prescription Plan Details

In-Network Pharmacy1 Out-of-Network Pharmacy1
Retail (30-day supply)2
Generic/Brand/Non-Formulary
10%/15%/20% after deductible 50% after deductible
Mail Order (90-day supply)2
Generic/Brand/Non-Formulary
10%/15%/20% after deductible Not Covered

1 Individual deductible and OOP maximum only apply to employees enrolled in employee-only tier. Members in dependent tiers must satisfy the family deductibles and OOP maximums.
2 Deductible waived for preventive medications.

Specialty Pharmacy Program

The first fill can be obtained at a retail pharmacy, but future fills MUST be obtained at Aetna Specialty Pharmacy. The Aetna Specialty Pharmacy program can deliver self-injectable drugs and other specialty medications that require special handling to your home, your doctor’s office or any other location you choose.

Employee Contributions for 2017

Per Paycheck Rates

Plan Employee Only Employee +
Spouse/Domestic Partner
Employee + Child(ren) Employee + Family
HSA PPO $0 $54.02 $38.90 $97.24

Per paycheck contributions are 24 times per year

Dependent Eligibility

  • Your spouse or domestic partner. Please note: after-tax contributions and imputed income may apply when covering a domestic partner. See the Domestic Partner Imputed Income Rate Table for details.
  • Your child(ren) and your spouse’s / domestic partner’s child(ren), your foster child(ren) are eligible for medical coverage until age 26, regardless of student status.

For more details, see the Aetna HSA PPO Summary of Benefits and Coverage (SBC).

Contact Us

Aetna
Phone: 1-855-521-6853
Visit website


Aetna Pharmacy Benefits
Phone: 1-888-792-3862
Visit website


Aetna Specialty Care Rx
Phone: 1-866-782-2779
Visit website


Benefit Center
1-888-VMWARE8, option ‘US Benefits’
hrbenefitadmin@vmware.com

Resources

Aetna Concierge
Aetna’s Doc Find
Aetna HDHP 2016 Documents
Aetna HSA PPO Benefit Summary 2017
Aetna HSA PPO Schedule of Benefits 2017
Aetna HSA PPO Summary of Benefits and Coverage (SBC) 2017
Aetna HSA PPO Summary Plan Description (SPD) 2017
Aetna HSA PPO Website
Aetna Medical Claim Form
Aetna Member ID Card
Aetna Mobile
Aetna Navigator Registration Guide
Aetna Pharmacy Claim Form
Aetna Pharmacy Drug Guide 2017
Aetna Premier Plus Formulary List 2017
Aetna Premier Plus with Precertification Formulary List 2017
Aetna Preventive Medicine List
Aetna Plan Selection and Cost Estimator Tool
Aetna Specialty Pharmacy Refill Information
Benefits Contact Quick Reference Guide
Domestic Partner Imputed Income Rate Table
HSA Proof of Other Medical Coverage Form
Palo Alto Medical Foundation Mobile Clinic