With the Choice Plan, you have the flexibility to use in-network or out-of-network providers. However, if you use an out-of-network provider for medical services these expenses generally are reimbursed at a lower level than in-network expenses, after you have met the out-of-network deductible.

For most covered services, you must satisfy a deductible before coverage begins. The deductible does not apply to most preventive care services.

Family Deductible

The family deductible represents the most a family will have to pay in individual deductibles in any calendar year. Only covered expenses that count toward your or your dependent's individual deductible can be applied toward the family deductible. The family deductible can be met as follows:

Deductible expenses cross-apply between in-network and out-of-network limits.

Coinsurance refers to the portion of a covered expense that you pay after you have met the deductible. For example, if the plan pays 80% in-network covered expenses, your coinsurance for these expenses is 20%.

The out-of-pocket maximum for medical services rendered in the network is $3,000 individual/$6,000 family or $6,000 individual/$12,000 family out-of-network. This amount represents the most you will have to pay out of your own pocket in a calendar year. This amount does not include penalties, charges above the MAA, prescription drug expenses or services not covered under Choice Plan. Once this out-of-pocket maximum is met, covered medical expenses are payable at 100% of the negotiated rate contracted with the Claims Administrator for in-network services (or 100% of MAA for out-of-network services) for the remainder of the calendar year. In-network copays for medical services also apply to the out-of-pocket maximums; once the out-of-pocket maximum has been satisfied, no additional in-network medical copays will apply for the remainder of the plan year. Prescription drug copays are subject to a separate out-of-pocket maximum.

Eligible medical expenses within a family can be combined to meet the family out-of-pocket maximum, but no one person can apply more than the individual out-of-pocket maximum amount ($3,000 in-network/$6,000 out-of-network) to the family out-of-pocket maximum ($6,000 in-network/$12,000 out-of-network).

Not all expenses count toward your medical out-of-pocket maximum. Among those that do not count are:

To help you manage the high cost of prescription drugs, there is also a separate annual prescription drug out-of-pocket maximum. Once you reach the prescription drug out-of-pocket maximum of $1,500 individual/$3,000 family, the plan pays the full cost of prescription drug expenses for the remainder of the year.

Out-of-pocket maximum expenses cross-accumulate between in-network and out-of-network limits.

When seeking primary care services, you should choose a provider from the PCPs in the directory of network providers. You may choose a pediatrician as the PCP for your covered child. Women may also select an OB/GYN without referral from their PCP. A directory of the providers who participate in the Choice Plan network is available from the Claims Administrator. You may call or visit the Claims Administrator's website:

If you need the services of a specialist, you may seek care from a specialist directly without a referral. Once you meet your deductible, the plan will pay 80% of covered in-network expenses.

When you see an in-network allergist, once you meet your deductible, you will be expected to pay 20% of the first office visit. If you receive an allergy injection only (without a physician's office visit charge), benefits will be covered at 100%. If you receive services other than an allergy injection, coinsurance will apply.

Preventive care services are covered at 100% in-network with no deductible to meet for the Choice Plan.

Each participant in the Choice Plan has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible, and expenses that exceed the $250 credit are covered at 60% of MAA. For additional information on what is considered to be preventive care, see "Your Medical Options."

Preventive care services include:

In addition, Choice Plan will cover both cancer-screening tests and well-adult and well-child immunizations performed by in-network providers at 100%, not subject to deductible. Routine cancer screenings are:

Preventive care services covered in the network at 100% will be reviewed annually and updated prospectively to comply with recommendations of the:

Choice Plan offers additional coverage for routine care services to help in the early detection of health problems.

Aetna: Covered expenses include a complete routine eye exam that includes refraction and glaucoma testing. A routine eye exam does not include a contact lens exam.

Aetna: Covered expenses include charges for an audiometric hearing exam if the exam is performed by:

Services provided in a hospital emergency room from a network provider are covered at 80% for covered services after the deductible has been met.

When emergency care is necessary, please follow the guidelines below:

Urgent care centers are listed in the provider directory available on the Claims Administrators' websites. You do not need a referral or any precertification to use an urgent care center. Services provided by an urgent care center are covered at 80% for covered services after the deductible has been met.

Aetna: Call your PCP if you think you need urgent care. You may contact any physician or urgent care provider, in or out of network, for an urgent care condition if you cannot reach your physician. If it is not feasible to contact your physician, please do so as soon as possible after urgent care is provided. In-network providers are required to provide urgent care coverage 24 hours a day, including weekends and holidays. If you need help finding an urgent care provider, you may call Member Services at the toll-free number on your ID card, or you may access Aetna's online provider directory at www.aetna.com. Follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. Once you have been treated and discharged, you should contact your physician for any necessary follow-up care.

Out-of-Network Multiple Surgical Procedure Guidelines

If you are using an out-of-network provider for a surgical procedure, the following multiple surgical procedure guidelines will apply.

If more than one procedure will be performed during one operation — through the same incision or operative field — the plan will pay according to the following guidelines:

If billed separately, incidental surgeries will not be covered. An incidental surgery is a procedure performed at the same time as a primary procedure and requires few additional physician resources and/or is clinically an integral part of the performance of the primary procedure.

An in-network provider contracts with the Choice Plan Claims Administrator to participate in the network. Under the terms of this contract, an in-network provider may not charge you or the Claims Administrator for the balance of the charges above the contracted negotiated rate for covered services.

You may agree with the in-network provider to pay any charges for services or supplies not covered under the Choice Plan or not approved by the Choice Plan. In that case, the in-network provider may bill charges to you. However, these charges are not covered expenses under the Choice Plan and are not payable by the Claims Administrator.

For information about how to file a claim or appeal a denied claim, see "Claims and Appeals for Aetna Medical Plans" or "Claims and Appeals for Anthem BlueCross BlueShield Medical Plan."