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CALIFORNIA HMO Medical Plan
Aetna Value Network HMO
P.O. Box 14089
Lexington, KY 40512
www.aetna.com
Group #: US0378525
Member Services - (877) 402-8742
Behavioral Health - (800) 424-5928
Pharmacy Management - (800) 238-6279
New Mental Health Information in 2010
The plan will be amended effective January 1, 2010 to comply with the Federal Mental Health Parity Act. Mental Health and substance abuse will be covered as any physical illness under the HMO plan.
New 2010 Mental Health Coverage
| Mental Health | Coverage |
| Inpatient Care | 100% covered |
| Outpatient Care | $15 co-pay |
| Alcohol & Substance Abuse | |
| Inpatient Hospitalization/Detoxification | 100% covered |
| Outpatient Services | $15 co-pay |
A Health Maintenance Organization (HMO) medical plan is available to employees and dependents in California only. TSRI Graduate Students and all Florida employees are not eligible for this plan. The network of providers is the Aetna Value Network HMO. To search for a primary care physician click the link to the right or call Aetna at (877) 402-8742. Please note that Scripps Clinic is not available in the Aetna Value Network HMO.
An HMO plan requires an employee to designate a primary care physician who will coordinate all care received including providing referrals to specialists. Prescriptions and Mental Health services are provided through the HMO plan directly. Vision services are provided separately through MES Vision.
The chart below outlines the main provisions of the HMO medical plan.
| Medical | Coverage |
| Outpatient Services | |
| Deductible |
None |
| Out-of-Pocket Max | $1500 per person $3000 per family |
| Office Visits | $15 co-pay |
| Surgery | 100% covered |
| Lab/X-ray | $15 co-pay |
| Inpatient Services | |
| Urgent Care | $50 per visit |
| Emergency Room | $100 per visit |
| Hospital Charges | 100% covered |
| Other Services | |
| Well Baby Care | $15 co-pay |
| Adult Periodic Exams | $15 co-pay |
| Well Woman Exams | $15 co-pay |
| Immunizations | $15 co-pay |
| Chiropractic Care | $15 co-pay; 20 visits/year |
| Acupuncture | None |
| Prescriptions | Retail (30 day supply) |
Mail Order (90 day supply) |
|---|---|---|
| Generic | $10 |
$20 |
| Brand Name | $25 |
$50 |
| Non-Formulary | $50 |
$100 |
Mental Health |
Coverage |
|---|---|
| Inpatient Care | 100%; non-severe limited to 30 days/year |
| Outpatient Care | Severe: $15 co-pay Non-Severe: $25 co-pay; 20 visits/year |
| Alcohol & Substance Abuse | |
| Inpatient Hospitalization/ Detoxification | 100%: 30 days/year |
| Outpatient Services | $15 co-pay Rehab limited to 20 visits/year |
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ADDITIONAL LINKS
FAQ's (Frequently Asked Questions)
Getting to Know Your Aetna Prescription Drug Plan
TSRI On-Site Counseling Services
FORMS
Prescription Pre-certification Form
Transition of Coverage Request
Primary Care Physician Designation Form (for new adds only!)