$2,850 DEDUCTIBLE PLAN WITH HSA

IQVIA Benefits Handbook


	In-Network	Out-of-Network*
Annual Deductible
Individual	$2,850	$5,700
Family	$5,700	$11,400
Coinsurance for most covered services	70%, after deductible	50%, after deductible
Annual Out-of-Pocket Maximum**
Individual	$5,500	$11,000
Family	$11,000	$22,000
Lifetime Maximum	None
Preventive Care
Routine care and office visits (includes X-ray and lab work when billed as preventive care)	100%	50%, after deductible
Immunizations: (including travel immunizations and flu shots)
Children through age 2	100%	50%, after deductible
Children age 3 and over and adults	100%	50%, after deductible
Mammograms***	100%	50%, after deductible
Pap smears	100%	50%, after deductible
Other routine cancer screenings	100%	50%, after deductible
Skin cancer screenings when provider bills as preventive	100%	50%, after deductible
Obesity or health diet counseling	100%	50%, after deductible
Screening and counseling services for misuse of alcohol or drugs	100%	50%, after deductible
Screening and counseling services to stop using tobacco products	100%	50%, after deductible
Sexually transmitted infection counseling	100%	50%, after deductible
Physician Services
Office visits Primary care physician (PCP) Specialty care physician (Includes X-ray and lab work when performed and billed by the physician's office) Nurse practitioners (NP) and Physicians Assistants (PA) to be billed based on provider office type	70%, after deductible	50%, after deductible
Telemedicine (Teladoc) – Available with the Aetna plans only	$40 copay until deductible is met; then 80% coinsurance
Surgery (physician's office)	70%, after deductible	50%, after deductible
Allergy injections/antigens/serum Note: Covers the injections/serum when there is no office visit charged. Standard is to waive the copay and apply the plan deductible and plan coinsurance.	70%, after deductible	50%, after deductible
Allergy testing and treatment (dispensed by physician's office) Note: Covers both testing and treatment, including injections/serum when billed with an office visit. Standard is to cover same as the PCP or specialist office visit.	70%, after deductible	50%, after deductible
Hospital Services
Inpatient hospital care (semi-private room)	70%, after deductible	50%, after deductible
Inpatient physician's visits/consultations	70%, after deductible	50%, after deductible
Inpatient professional services (surgeon, radiologist, etc.)	70%, after deductible	50%, after deductible
Outpatient physician's visits/consultations	70%, after deductible	50%, after deductible
Outpatient facility services Office/ambulatory surgery center PCP and specialist copay will apply based on provider status	70%, after deductible	50%, after deductible
Outpatient professional services (surgeon, radiologist, etc.)	70%, after deductible	50%, after deductible
Other inpatient health care facilities (e.g., skilled nursing facility, rehab hospital, sub-acute facility)	70%, after deductible	50%, after deductible
Maternity Care (Employee and dependent daughters)
Physician's office (visits)	Aetna: 70%, after deductible Kaiser: 100%	50%, after deductible
Physician services (delivery)	70%, after deductible	50%, after deductible
Mental Health and Substance Abuse
Inpatient services (facility, professional and other inpatient services)	70%, after deductible	50%, after deductible
Outpatient (individual or group therapy office visit)	70%, after deductible	50%, after deductible
Outpatient services (facility, professional and other outpatient services)	70%, after deductible	50%, after deductible
Emergency Services
Ambulance	70%, after deductible	70%, after deductible
Emergency room (waived if admitted)	70%, after deductible	70%, after deductible
Urgent care	70%, after deductible	50%, after deductible
Other Services
Abortion/Voluntary Sterilization (dependents covered)	70%, after deductible	50%, after deductible
Acupuncture (Aetna: 12 visits per calendar year/Kaiser: 30 visits per calendar year)	70%, after deductible	50%, after deductible
Autism and ABA Therapy	70%, after deductible	50%, after deductible
Bariatric surgery (One per lifetime; no dollar limit)	70%, after deductible	50%, after deductible
Chiropractic care (60 visits per calendar year)	70%, after deductible	50%, after deductible
Clinical trials (routine patient care services incurred as a participant in an approved clinical trial conducted in relation to the prevention, detection or treatment of cancer or another life-threatening disease or condition)	Covered according to the type of benefit and the place where the service is received.	Covered according to the type of benefit and the place where the service is received.
Dental treatment (due to accidental injury to sound natural teeth provided dental treatment is started within 12 months of an accident, TMJ medical treatment and appliances)	70%, after deductible	50%, after deductible
Diagnostic X-ray & lab	70%, after deductible	50%, after deductible
Durable medical equipment	70%, after deductible	50%, after deductible
Genetic testing	70%, after deductible	50%, after deductible
Hearing aids (testing and exam)	70%, after deductible; subject to office visit copays	50%, after deductible
Hearing aids (hardware - $1,000 per ear per calendar year)	70%, after deductible (hardware only; deductible, coinsurance and copays do not apply to limit)	50%, after deductible
Home health care (120 visits per calendar year)	70%, after deductible	50%, after deductible
Hospice services	70%, after deductible	50%, after deductible
Skilled nursing care (inpatient—120 days per calendar year)	70%, after deductible	50%, after deductible
Private duty nursing (outpatient—60 visits per calendar year)	70%, after deductible	50%, after deductible
Organ transplants: Centers of Excellence Non Centers of Excellence	70%, after deductible 50%, after deductible	N/A 50%, after deductible
Prosthetic devices	70%, after deductible	50%, after deductible
Outpatient rehabilitative therapy	70%, after deductible	50%, after deductible
Outpatient therapy services (cardiac rehab, infusion therapy, chemotherapy/radiation, dialysis/hemodialysis)	70%, after deductible	50%, after deductible

* Generally, all out-of-network expenses are subject to the Maximum Reimbursable Charge (MRC) limit. You should note that since in-network charges for covered services have been negotiated with the providers, MRC limits do not apply.

** Annual deductible applies toward out-of-pocket maximum.

***In the Aetna plans, the first mammogram in a calendar year will be covered at 100% by the plan. All subsequent mammograms in a calendar year are subject to the applicable plan provisions.

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