Traditional PPO
The Traditional PPO medical plan has full coverage for in-network preventive care with you sharing the cost of other services through co-pays, coinsurance and your deductible. You are eligible to enroll in the General Purpose Flexible Spending Account (GPFSA) for your out-of-pocket expenses, when enrolled in the Traditional PPO plan.
The Traditional PPO plan gives you the option to visit any provider, allowing you to shop around when you need health care. 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.)
Traditional PPO Plan Details
| In-Network | Out-of-Network | |
|---|---|---|
| Annual Deductible1 | Individual: $500 Family: $1,500 |
Individual: $500 Family: $1,500 |
| Annual Out-of-Pocket (OOP) Maximum 2 | Individual: $2,350 Family: $7,050 |
Individual: $6,250 Family: $18,750 |
| Employee Coinsurance | 10% after deductible | 30% of UCR3, after deductible |
| Preventive (Annual Physicals, Well Care Exams) | 100% covered, not subject to deductible | 30% of UCR3, after deductible |
| Physician Visits | Primary Care: $20 co-pay Specialist: $30 co-pay |
30% of UCR3, after deductible |
| Lab and X-Ray | 10% after deductible | 30% of UCR3, after deductible |
| Emergency Room | $100 co-pay, then 10% of UCR4 | $100 co-pay, then 10% |
| Ambulance | 10% after deductible | 30% of UCR3, after deductible |
| Hospitalization | 10% after deductible | 30% of UCR3, after deductible; $500 per confinement deductible |
| Chiropractic | $30 co-pay per visit Up to 20 visits per year |
30% after deductible Up to 20 visits per year |
| Acupuncture | $30 co-pay per visit Up to 12 visits per year |
30% after deductible Up to 12 visits per year |
| Physical Therapy | $30 co-pay per visit | 30% after deductible |
| Speech Therapy4 | $30 co-pay per visit | 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.
2 OOP maximum includes Prescription Rx.
3 Usual, customary, and reasonable charges.
4 Available to those with conditions of medical necessity.
Prescription Rx
Coverage for prescription drugs is included when you enroll in the Traditional PPO plan. 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 Pharmacy | Out-of-Network Pharmacy | |
|---|---|---|
| Retail (30-day supply) Generic/Brand/Non-Formulary |
10%/25%/40% after deductible |
50% after deductible |
| Mail Order (90-day supply) Generic/Brand/Non-Formulary |
10%/25%/40% after deductible |
Not Covered |
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 |
|---|---|---|---|---|
| Traditional PPO | $57.83 | $154.20 | $127.22 | $231.30 |
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), 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 Traditional 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
Phone 1-888-VMWARE8, option ‘US Benefits’
hrbenefitadmin@vmware.com
Resources
Aetna Concierge
Aetna’s Doc Find
Aetna Medical Claim Form
Aetna Member ID Card
Aetna Mobile
Aetna Navigator Registration Guide
Aetna Pharmacy Claim Form
Aetna Pharmacy Drug Guide 2017
Aetna Plan Selection and Cost Estimator Tool
Aetna PPO 2016 Documents
Aetna Premier Plus Formulary List 2017
Aetna Premier Plus with Precertification Formulary List 2017
Aetna Preventive Medicine List
Aetna Specialty Pharmacy Refill Information
Aetna Traditional PPO Benefit Summary 2017
Aetna Traditional PPO Schedule of Benefits 2017
Aetna Traditional PPO Summary of Benefits and Coverage (SBC) 2017
Aetna Traditional PPO Summary Plan Description (SPD) 2017
Benefits Contact Quick Reference Guide
Domestic Partner Imputed Income Rate Table
Palo Alto Medical Foundation Mobile Clinic