4.5 Pruebas usando servidor de OpenSim localmente y Moodle en servidor
4.2.1 Funcionalidad de las Plataformas Interconectadas
PPO+Account Schedule of Benefits Effective January 1, 2012
The PPO+Account is administered by Aetna (the service representative).
Annual deductible (applies unless otherwise noted)
n $1,500 employee only
n $2,625 employee + spouse or child(ren) n $3,750 employee + spouse and child(ren)
The deductible may be met by one person or a combination of family members
Network and nonnetwork expenses apply to the deductible Coinsurance percentage Network: Plan pays 90% Nonnetwork: Plan pays 60% Annual out-of-pocket maximum Network:
n $1,600 employee only n $2,800 employee + spouse or child(ren) n $4,000 employee + spouse and child(ren) Nonnetwork: n $3,200 employee only n $5,600 employee + spouse or child(ren) n $8,000 employee + spouse and child(ren)
Annual out-of-pocket maximum is in addition to the annual
deductible; it is combined for all family members; individual annual out-of-pocket maximums do not apply
Copayments You pay the network copayment listed below for routine vision examinations
Lifetime maximum benefit $2 million per individual (network and nonnetwork combined)
Details and Limits on Certain
Services and Supplies Network Provider* Nonnetwork Provider**,†
Ambulance 90% 90% (must meet definition of emergency medical condition); otherwise 60%
Christian Science practitioner and
sanatorium 90%; limits apply Same as network provisions Diagnostic X-ray and laboratory
services 90% 60%
Benefits Information (continued) Benefits Information (continued)
Benefits Information (continued) Benefits Information (continued)
PPO+Account Schedule of Benefits (continued) Effective January 1, 2012
The PPO+Account is administered by Aetna (the service representative).
Details and Limits on Certain
Services and Supplies Network Provider* Nonnetwork Provider**,†
Emergency room treatment Medical emergency (must meet definition of emergency medical condition)
90% Same as network provisions
All other treatment 90% 60% Hearing aids n 90% up to $800 per ear
n Limited to one aid per ear every
three benefit years
n Hearing aid overhaul in place of
new hearing aid after three benefit years
Same as network provisions
Hemodialysis n 90% for the first 30 months of
Medicare entitlement due to end stage renal disease
n Thereafter, Medicare is primary
and this plan is secondary
60%
Home health care 90% 60%
Hospice care n 90%; six-month maximum
n Skilled care of four or more hours
per day by a registered nurse, licensed practical nurse, or home health aide
n Respite care visits of 2 or more
hours per day up to 120 hours every three months
Same as network provisions
Hospital 90% 60%
Mental health treatment (including
eating disorders) Care is managed by and claims are administered by Aetna Covered inpatient, residential, or
intensive outpatient services 90% when obtained from a provider referred by Aetna 60% when obtained from a provider not referred by Aetna Covered outpatient or partial
hospital services
• 90% when obtained from a
provider referred by Aetna
• No precertification required for
first eight outpatient visits with a network provider; subsequent visits must be preapproved by Aetna or will be paid at the nonnetwork level
60% when obtained from a provider not referred by Aetna
Benefits Information (continued) Benefits Information (continued)
Benefits Information (continued) Benefits Information (continued)
PPO+Account Schedule of Benefits (continued) Effective January 1, 2012
The PPO+Account is administered by Aetna (the service representative).
Details and Limits on Certain
Services and Supplies Network Provider* Nonnetwork Provider**,†
Prescription drugs n Pharmacy benefits are provided through Aetna and Aetna Rx Home
Delivery
n Quantities and dosages for certain prescription drugs may be limited
by general plan provisions, clinically established guidelines, and/or FDA-approved labeling
Retail pharmacy card program Supply limited to 30 days (for certain preventive medications, annual deductible does not apply)
Generic drug 90%
Brand formulary drug 80% Brand nonformulary drug 70%
Mail-order pharmacy program Supply limited to 90 days (for certain preventive medications, annual deductible does not apply)
Generic drug 90%
Brand formulary drug 80% Brand nonformulary drug 70% Preventive care
Routine physical examinations (for employees, spouses, and children age 2 and older)
n 100% (annual deductible does
not apply) up to $500 each year per covered person, including physical examinations, related laboratory and X-ray charges as well as childhood and adult immunizations as recommended by the U.S. Preventive Services Task Force (USPSTF); covered expenses above the $500 maximum will be subject to the deductible and coinsurance
n Limited to one examination per
child every benefit year for age 2 through 18
n Limited to one examination per
person every three benefit years for age 19 through 34, then one examination per person every benefit year
Not covered when received in a network service area
Routine physical examinations (for children to age 2)
n 100% (annual deductible does
not apply)
n Limited to eight examinations
from birth to age 2
n Immunizations as recommended
by the USPSTF
Not covered when received in a network service area
Benefits Information (continued) Benefits Information (continued)
Benefits Information (continued) Benefits Information (continued)
PPO+Account Schedule of Benefits (continued) Effective January 1, 2012
The PPO+Account is administered by Aetna (the service representative).
Details and Limits on Certain
Services and Supplies Network Provider* Nonnetwork Provider**,†
Routine Pap tests, mammograms, prostate screenings, and colorectal screenings (including colonoscopies)
n 100% (annual deductible does
not apply)
n Covered as recommended by the
physician
Not covered when received in a network service area
Prostheses 90%; $500 annual limit for hair prostheses if undergoing
chemotherapy or radiation therapy (network and nonnetwork
combined)
60%; $500 annual limit for hair prostheses if undergoing chemotherapy or radiation
therapy (network and nonnetwork combined)
Spinal and extremity manipulations (such as chiropractic care)
n 90%
n Limited to 26 visits for spinal
and extremity manipulations combined per year (network and nonnetwork combined)
n 60%
n Limited to 26 visits for spinal
and extremity manipulations combined per year (network and nonnetwork combined) Substance abuse treatment Care is managed by and claims are administered by Aetna
Covered inpatient, partial hospital, residential, intensive outpatient, or outpatient services
n 90% when obtained from a
provider referred by Aetna
n No precertification required for
first eight outpatient visits with a network provider; subsequent visits must be preapproved by Aetna or will be paid at the nonnetwork level
60% when obtained from a provider not referred by Aetna
TMJ/MPDS treatment n 50%
n $3,500 lifetime maximum benefit
Same as network provisions Therapies
Neurodevelopmental therapy (for children 6 and younger)
n 90%
n Limited to $1,000 each benefit
year (network and nonnetwork combined)
n 60%
n Limited to $1,000 each benefit
year (network and nonnetwork combined)
Occupational, physical, and
speech therapy 90% 60%
Tobacco cessation treatment n 100% (annual deductible does
not apply)
n $500 lifetime maximum benefit
Same as network provisions
* The network payment level is based on the approved fees that the service representative negotiated for specific providers and services covered by the plan.
** The nonnetwork payment level is based on the usual and customary charge (as defined by this plan). You are
responsible for paying any charges in excess of the amount the service representative determines to be the usual and customary charge.
† For certain benefits, the plan will pay 90% of usual and customary charges if the service representative does not
Benefits Information (continued) Benefits Information (continued)
Benefits Information (continued) Benefits Information (continued)
Vision Care Program Schedule of Benefits Effective January 1, 2012
The vision care program is administered by Vision Service Plan (VSP, the service representative).
Services and Supplies VSP Plan
Vision examinations Paid in full after $15 copayment for VSP network provider; paid up to $50 for nonnetwork provider Lenses (two): Single vision $50* Bifocal $80* Trifocal $95* Lenticular $155* Frames $90*
Contact lenses (in place of allowances for
conventional lenses and frames above) $120*
* VSP network providers offer a 20 percent discount on complete pairs of prescription glasses and a 15 percent discount on contact lens examinations (evaluation and fitting); you pay the VSP network provider only the excess over the amounts shown in the schedule above. Nonnetwork provider charges for lenses, frames, and contact lenses are reimbursed up to the amounts shown in the schedule above; no discount applies.