• How Many Ultrasounds Does Aetna Cover
• Aetna Ultrasound Guidelines

View the 2021 Standard Option plan

A copay is like paying for repairs when something goes wrong. When your car gets serviced, you pay a set fee to the mechanic, just as you may pay a set fee, like $20, when you go to the doctor because you're sick. Inpatient services $300 copay/stay Not covered Max copay/calendar year: $900. If you are pregnant Office visits No charge Not covered Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. Ultrasound.) Max copay/calendar year: $900. Childbirth/delivery professional. Ultrasound.) Penalty of $500 for failure to obtain pre-authorization for out-of-network care may apply. Childbirth/delivery professional services 20% coinsurance after $250 copay/stay 90% coinsurance after $290 copay/stay Childbirth/delivery facility services 20% coinsurance after $250 copay/stay 90% coinsurance after $290 copay/stay.

1. $20 copay/visit, deductible doesn't apply 90% coinsurance. None Specialist visit $40 copay/visit, deductible. Doesn't apply 90% coinsurance None Preventive care /screening /immunization No charge 90% coinsurance, except no charge for flu & pneumonia vaccines You may have to pay for services that are not preventive. Ask your provider if the services.
2. Outpatient services $20 copay/ visit Not covered Prior authorization required. Inpatient services $250 copay/ per admission Residential stay: No Charge Not covered Prior authorization required. If you are pregnant Office visits No charge Not covered Maternity care may include tests and services described elsewhere in the SBC (i.e.

Traditional coverage. Affordable premiums.

With comprehensive care, this medical plan is the one you know and trust, with familiar benefits and coverage

When you enroll in GEHA’s Standard Option, you:

• Pay nothing for online doctor visits with access to certified doctors, including dermatologists, and licensed therapists through MDLIVE.
• Pay nothing for routine, in-network maternity care.
• Get a complete range of prescription services.

More Standard Option highlights:

• A 30-day supply of generic medication costs just $10.
• You can visit your primary care doctor for only a $15 copay each visit.
• This plan covers 100% of preventive care costs when you see an in-network provider.

2020 Rates

These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer that maintains your health benefits enrollment.

Self Only	Self Plus One	Self and Family
Non-Postal biweekly	$60.54	$130.18	$155.52
Postal biweekly – Category 1	$58.12	$124.97	$149.30
Postal biweekly – Category 2	$50.25	$108.05	$129.08
Monthly (retirees)	$131.18	$282.05	$336.96

Pay nothing for online doctor visits with access to certified doctors, including dermatologists, and licensed therapists through MDLIVE.

A 30-day supply of generic medication costs just $10.

You can visit your primary care doctor for only a $15 copay each visit.

Covered benefits for routine in-network maternity care and hospital stays.

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Costs for services in 2020

The table below summarizes your in-network cost for medical benefits with GEHA Standard Option. For complete information, refer to the GEHA Plan Brochure.

Copays

Copay	What you pay in-network
Primary physician office visit	$15
Specialist	$30
MinuteClinic (where available)	$10
Urgent care	$35
Annual eye exam	$5 through EyeMed

Other services

Service	What you pay in-network
Preventive lab services	Nothing with Lab Card
Well-child visit; up to age 22	Nothing
Adult routine screening	Nothing
Preventive dental care	50% of allowance, twice yearly

Maternity care

Service	What you pay in-network
Routine provider care	Nothing
Inpatient care	Nothing

Self Only	Self Plus One	Self and Family
Calendar-year deductible (in-network)	$350	$700	$700
Out-of-pocket-maximum (in-network)	$6,500	$13,000	$13,000

Prescriptions

The table below summarizes your cost for prescription drugs with GEHA’s Standard Option. For complete benefit information, including details on specialty drugs that are injected or infused, refer to the GEHA Plan Brochure.

To find a drug cost based on your benefit plan and prescription dosage, check your drug costs.

Retail pharmacy – 30-day supply

In-Network	Out of Network
Generic	$10	$10, plus difference between plan allowance and cost of drug
Preferred brand-name	50%, up to $200 max¤	50%, up to $200 max, plus difference between plan allowance and cost of drug**¤
Non-preferred brand-name	50%, up to $300 max¤	50%, up to $300 max, plus difference between plan allowance and cost of drug**¤

Mail service pharmacy – 90-day supply

In-Network	Out of Network
Generic	$20	n/a
Preferred brand-name	50%, up to $500 max¤	n/a
Non-preferred brand-name	50%, up to $600 max¤	n/a

¤If you choose a brand-name medication when a generic is available, you will be charged the generic copay plus the difference in cost between the brand-name and the generic.

**Retail fills eligible for a greater than a 30-day supply will be subject to the 50% coinsurance up to the maximum of $500 for preferred or $600 for non-preferred.

^GEHA supplemental benefits are neither offered nor guaranteed under contract with the FEHB, but are made available to all enrollees and family members who become members of a GEHA medical plan. For information on year-round savings for GEHAdental members, visit Savings for GEHA dental members.

How Many Ultrasounds Does Aetna Cover

Aetna Ultrasound Guidelines

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