Summary of Benefits and Coverage: Aetna Choice POS II

��Ĵ�ý Human Resources Benefits Health, Dental, and Voluntary Vision Benefits Health Insurance Summary of Benefits and Coverage: Aetna Choice POS II

Human Resources

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

��Ĵ�ý: Aetna Choice POS II

Coverage Period: 07/01/2025-06/30/2026

Coverage for: Individual + Family
Plan Type: POS

The Summary of Benefits and Coverage (SBC) document will help you choose a health . The SBC shows you how you and the would share the cost for covered health care services. NOTE: Information about the cost of this (called the ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact Kim Austin, Director of Benefits at kaustin@wlu.edu or 540-458-8921. For general definitions of common terms, such as , , , , , , or other underlined terms, see the . You can view the or call 1-888-982-3862 to request a copy.

Important Questions	Answers	Why This Matters:
What is the overall ?	For each Year, In-: Individual $750 / Family $1,500. Out-of-Network: Individual $1,000 / Family $2,000.	Generally, you must pay all of the costs from up to the amount before this begins to pay. If you have other family members on the plan, each family member must meet their own individual until the total amount of expenses paid by all family members meets the overall family .
Are there services covered before you meet your ?	Yes. Emergency care; plus in- office visits, inpatient hospital services & are covered before you meet your .	This covers some items and services even if you haven’t yet met the amount. But a or may apply. For example, this covers certain without and before you meet your . See a list of covered at
Are there other for specific services?	No.	You don’t have to meet for specific services.
What is the for this ?	In-: Individual $3,000 / Family $6,000. Out-of-Network: Individual $3,250 / Family $6,500.	The is the most you could pay in a year for covered services. If you have other family members in this , they have to meet their own until the overall family has been met.
What is not included in the ?	, charges, health care this doesn’t cover & penalties for failure to obtain for services.	Even though you pay these expenses, they don’t count toward the .
Will you pay less if you use a ?	Yes. See or call 1-888-982-3862 for a list of In-.	This uses a provider . You will pay less if you use a in the . You will pay the most if you use an , and you might receive a bill from a for the difference between the charge and what your pays (). Be aware, your might use an for some services (such as lab work).Check with your before you get services.
Do you need a to see a ?	No.	You can see the you choose without a .

All and costs shown in this chart are after your has been met, if a applies.

Common Medical Event	Services You May Need	What You Will Pay: In-Network Provider (You will pay the least)	What You Will Pay: Out-of-Network Provider (You will be the most)	Limitations, Exceptions, & Other Important Information
If you visit a health care office or clinic	Primary care visit to treat an injury or illness	$25 /visit, doesn’t apply	20%	None
If you visit a health care office or clinic	visit	$50 /visit, doesn’t apply	20%	None
If you visit a health care office or clinic	/ /immunization	No charge	20%	You may have to pay for services that aren’t preventive. Ask your if the services needed are preventive. Then check what your will pay for.
If you have a test	(x-ray, blood work)	10% for laboratory; $20 /visit for x-ray, doesn’t apply	20%	None
If you have a test	Imaging (CT/PET scans, MRIs)	$100 /visit, doesn’t apply	20%	None
If you need drugs to treat your illness or condition More information about is available at	Generic drugs	Not covered	Not covered	Not covered
If you need drugs to treat your illness or condition More information about is available at	Preferred brand drugs	Not covered	Not covered	Not covered
If you need drugs to treat your illness or condition More information about is available at	Non-preferred brand drugs	Not covered	Not covered	Not covered
If you need drugs to treat your illness or condition More information about is available at		Not covered	Not covered	Not covered
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	$300 /visit, doesn’t apply	20%	None
If you have outpatient surgery	Physician/surgeon fees	No charge	20%	None
If you need immediate medical attention		$300 /visit, doesn’t apply	$300 /visit, doesn’t apply	Out-of- emergency use paid the same as in-. No coverage for non-emergency use.
If you need immediate medical attention		$300 /trip, doesn’t apply	$300 /trip, doesn’t apply	Out-of- emergency use paid the same as in-. Non-emergency transport: not covered, except if pre-authorized.
If you need immediate medical attention		$50 /visit, doesn’t apply	$50 /visit, doesn’t apply	No coverage for non-urgent use
If you have a hospital stay	Facility fee (e.g., hospital room)	$500 /stay, doesn’t apply	20%	Penalty of $400 for failure to obtain for out-of-network care.
If you have a hospital stay	Physician/surgeon fees	10%	20%	None
If you need mental health, behavioral health, or substance abuse services	Outpatient services	Office: $25 /visit, doesn’t apply; other outpatient services: no charge	Office & other outpatient services: 20%	None
If you need mental health, behavioral health, or substance abuse services	Inpatient services	$500 /stay, doesn’t apply	20%	Penalty of $400 for failure to obtain for out-of-network care.
If you are pregnant	Office visits	No charge	20%	does not apply for . Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Penalty of $400 for failure to obtain for out-of-network care may apply.
If you are pregnant	Childbirth/delivery professional services	10%	20%	does not apply for . Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Penalty of $400 for failure to obtain for out-of-network care may apply.
If you are pregnant	Childbirth/delivery facility services	$500 /stay, doesn’t apply	20%	does not apply for . Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Penalty of $400 for failure to obtain for out-of-network care may apply.
If you need help recovering or have other special health needs		10%	20%	100 visits/ year. Penalty of $400 for failure to obtain for out-of-network care.
If you need help recovering or have other special health needs		$50 /visit, doesn’t apply	20%	None
If you need help recovering or have other special health needs		No charge	20%	None
If you need help recovering or have other special health needs		10%	20%	100 days/ year. Penalty of $400 for failure to obtain for out-of-network care.
If you need help recovering or have other special health needs		10%	20%	Limited to 1 for same/similar purpose. Excludes repairs for misuse/abuse.
If you need help recovering or have other special health needs		$500 for inpatient; 0%	20%	Penalty of $400 for failure to obtain for out-of-network care.
If your child needs dental or eye care	Children’s eye exam	No charge	20%	1 routine eye exam/12 months.
If your child needs dental or eye care	Children’s glasses	No charge	No charge	$150 maximum/12 months.
If your child needs dental or eye care	Children’s dental check-up	Not covered	Not covered	Not covered

Excluded Services & Other Covered Services:

Services Your Generally Does NOT Cover (Check your policy or document for more information and a list of any other .)

Cosmetic surgery
Dental care (adult & child)
Glasses (Child)
Long-term care
Non-emergency care when traveling outside the U.S.
Routine foot care
Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your document.)

Acupuncture - 10 visits/ year for disease, injury & chronic pain.
Bariatric surgery - Limited to in-.
Chiropractic care - 30 visits/ year.
Hearing aids - $3,000 maximum/lifetime.
Infertility treatment - For more information & exceptions, see policy document provided by your employer or call the number on your ID card.
Private-duty nursing - 20- 8 hour shifts/ year.
Routine eye care (adult) - 1 routine eye exam/12 months.

Your Rights to Continue Coverage: If you would like to continue coverage after your employment ends, contact iSolved at 866-320-3040 for information and enrollment.

If your group health coverage is subject to ERISA, you may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
Other coverage options may be available to you too, including buying individual insurance coverage through the . For more information about the , visit or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your for a denial of a . This complaint is called a or . For more information about your rights, look at the explanation of benefits you will receive for that medical . Your documents also provide complete information on how to submit a , , or a for any reason to your . For more information about your rights, this notice, or assistance, contact:

If your group health coverage is subject to ERISA, you may contact Aetna directly by calling the toll-free number on your Medical ID Card, or by calling our general number at 1-888-982-3862. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or
For non-federal governmental group health , you may also contact the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or .
Additionally, a consumer assistance program can help you file your . Contact information is at: .

Does this plan provide Minimum Essential Coverage? Yes.

generally includes , available through the or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of , you may not be eligible for the .

Does this plan meet Minimum Value Standards? No.

If your doesn’t meet the , you may be eligible for a to help you pay for a through the .

Human Resources

Kim Austin

Deputy Director of Human Resources and Director of Benefits

P: 540-458-8921
E: kaustin@wlu.edu

Jason Bunn

Manager of Work-Life Programming and Benefits Specialist

P: 540-458-8923
E: jbunn@wlu.edu

Human Resources

P: 540-458-8920
F: 540-458-8060
E: humanresources@wlu.edu

Mailing Address:
Human Resources
204 W. Washington Street
��Ĵ�ý
Lexington, Virginia 24450

Physical Address:
2 S Main Street
Lexington, VA 24450

���Ĵ�ý