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Exclusive Provider Organization (EPO) Plan

The Exclusive Provider Organization (EPO) is a comprehensive medical plan that covers only in-network providers and facilities.

Beginning January 1, 2017, the EPO plan will be administered by Aetna. For more details about this change, please see Key Changes in 2017. The EPO plan uses the Aetna Select (Open Access) nation-wide network of doctors and hositals. You pay a co-payment at the point of service and the university covers the remaining costs. If you choose to see a doctor or use a hospital outside the EPO's network, you pay the full cost of the care you receive. 

View detailed information about the Aetna EPO plan

Basics  

Overview

You may visit any Aetna Select (Open Access) EPO network doctor or hospital.

For certain services or procedures Aenta may require use of certain providers within their network.

There is no benefit if you see a Non-Network provider, except for emergency or urgent care.

Group #868277

Pre-Authorization Requirement

Pre-authorization required for all elective inpatient and outpatient procedures.

PENALTY for not pre-authorizing: benefit reduced to 50% of Aetna Allowed Amount. You pay balance of all charges not covered by Aetna. Out-of-Pocket Maximum does not apply.

Office copays

$30 copay primary/$75 copay specialist

 

Deductible

No deductible

Out-of-Pocket Maximum

$3,500 per individual/$7,000 family

Combined Network or Non-Network. A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.)

PREVENTATIVE CARE  

Physical exams for adults

100%

Physical exams for children

100%

Pap smears

100% (as part of the office visit)

Immunizations

100%

Travel immunizations not covered.

Well-woman visits 100%
PRESCRIPTION DRUGS  

Pharmacy (Retail)

Aetna Network pharmacy:
$10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply

Non-Network pharmacy: Member pays co-payment plus 25% of billed charges

Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime

Mail order drug program

$20 generic; $80 brand name; $200 non-formulary -- up to a 90-day supply

Must use Aetna's mail-order service

Birth Control Pills

Included in Prescription Drug benefit
 

Traveling Outside the U.S.

Benefits will be provided for covered services you receive anywhere within the Aetna network. Aetna has network providers outside of California and you can access service outside of California through the Aetna Select (Open Access) network.  Outside the U.S. only emergency services are covered.

Before traveling abroad, call Aetna Customer Service at 888-922-3862 to find out what you need to make your plan work for you when you travel. For more information visit the Aetna’s website

In an emergency, go directly to the nearest hospital. As soon as possible, you should call Aetna at (888) 922-3862 24 hours a day, seven days a week.