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TSRI Graduate Student PPO Plan

Contact

Aetna
P.O. Box 14079
Lexington, KY 40512-4079
Group Number: 805400

Tel: (877) 204-9186
www.aetna.com

Information

A Preferred Provider Organization (PPO) medical plan is available to TSRI Graduate Students. The plan is administered through Aetna and the provider network is Aetna Choice POS II. To find a provider, visit www.aetna.com/docfind or call Aetna at: (877) 204-9186.

TSRI Graduate Student PPO Plan

Service Graduate Student Plan
 
In-Network
Non-Network
Outpatient Services
Deductible
$0
$200 per person/$600 per family
Out-of-Pocket Max
$0
$2000 per person/$4000 per family
Office Visit
100%
70%
Surgery
100%
70%
Lab/X-ray
100%
70%
Impatient Services
Deductible (per admit)
$0
$200
Hospital Charges
100%
70%
Other Services
Well Baby Care
100%
None
One Annual Routine Exam
100%
None
Cancer Screening
100%
70%
Immunizations
100%
None
Chiropractic Care*
100%
70%
Acupuncture*
100%
100%
*20 visits per year.

Prescriptions

OptumRx Retail (30 day supply) Mail Order (90 day supply)
Rx Annual Deductible $100/person, $200/family (applies to brand formulary and non-formulary drugs only)
Generic
$10
$20
Formulary
Brand Name
$35
$70
Non-Formulary Brand Name
$60
$120

Mental Health

Services Network Provider Non-Network Provider
Deductible Comgined with medical plan
Out-Of-Pocket Max (per calendar year) Combined with medical plan
Inpatient
100%
70% after $200 co-pay
Outpatient
100%
70%

Live and Work Well Website

www.liveandworkwell.com - This site provides many tools and resources that can help improve life at work and at home includes health and wellness articles, educational resources, chats with experts, financial fitness tools such as retirement calculators and much more.

TSRI participants may access the site by logging in with the Institute’s Optum Health group plan number 10730. If you would like to access mental health services through a Optum Health network provider, please call the Optum Health 24-hour hotline at (800) 888-2998, for pre-authorization. Services provided by a non-network provider do not require pre-authorization.