AETNA HMO

Customer Service # 1-800-323-9930 http://www.aetna.com/

BENEFITS
Preventive Care
Routine Physical Exams – Adults and children Immunizations Gynecological (Up to 2 visits/year)	$15 co-pay $15 co-pay $15 co-pay
Prescription Drugs
Generic Brand Formulary Mail Order (up to a 90 day supply) Contraceptives	$10 co-pay $20 co-pay $35 co-pay $20/$40/$70 co-pay Covered
Outpatient Care
Physician Office Visits X-rays & Laboratory Tests Physical and Occupational Therapy, Including Chiropractic Care Speech Therapy Diagnostic Procedures and/or Surgery Performed in a Hospital or Outpatient Surgical Care	$15 co-pay $15 co-pay $15 co-pay $15 co-pay No co-pay
Inpatient Care
Hospitalization - Semi-Private Room and Board Physicians’, Surgeons’ and Nursing Services and Medications Restorative Physical & Occupational Therapy	No co-pay No co-pay $15 co-pay
Maternity Care
Pre-Natal & Post-Natal (from effective date of Aetna coverage) Hospital Services for Mother & Child (including all newborn costs even if mother is discharged and newborn requires continued hospitalization)	$15 co-pay First visit No co-pay
Vision Care
Routine Eye Exam Allowances for frames, glasses, and lens	$15 co-pay $100 reimbursement every 24 months
Mental Health
Outpatient Visits, 20 visits per year Inpatient, 35 days	$25 co-pay No co-pay
Substance Abuse
Detoxification Outpatient Rehabilitation, 60 visits	No co-pay $15 co-pay
Home Health or Hospice Care
Physicians House calls	$15 co-pay
Emergency Care
Emergency Room (co-pay waived if admitted)	$50 co-pay
Other Benefits
Pediatric Preventive Dental Exam	$15 co-pay
Durable Medical Equipment	No co-pay

Counties Covered:

New York: Bronx, Brooklyn, Manhattan, Nassau, Orange, Putnam, Queens, Rockland, Staten Island, Suffolk, Westchester, Dutchess, Ulster, and Sullivan