KingCare<sup>SM</sup> Benefits at a Glance

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KingCare^SM Benefits at a Glance

The following tables show what KingCare^SM pays for covered expenses, depending on whether you receive the gold, silver or bronze out-of-pocket expense level. (For important details, be sure to read "How the Healthy Incentives^SM Program Works" and "Knowing What's Covered and What's Not.") All covered out-of-network expenses are paid based on reasonable and customary (R&C) charges, as determined by the plan. That means if you go to an out-of-network provider and the charges are more than R&C charges for those services, you pay the additional charges. (For important details about reasonable and customary charges, see "Reasonable and Customary (R&C) Charges.")

Plan Features

The following table identifies some plan features, including your annual deductibles, out-of-pocket maximums and how benefits are determined for most covered expenses.


Plan Feature	KingCare^SM Gold	KingCare^SM Silver	KingCare^SM Bronze
Provider choice	You may choose any qualified provider, but you receive higher coverage when you use network providers. Reimbursement for out-of-network medical services is based on reasonable and customary (R&C) rates, and reimbursement for out-of-network prescription drug services is based on the rates Express Scripts pays its network pharmacies. You pay amounts in excess of these rates.
Annual deductible	$100/person; $300/family Deductible amounts applied to charges incurred in the last three months of the calendar year are carried over and applied to the next year's deductible. The deductible doesn't apply to prescription drugs, preventive care or hearing aids.	$300/person; $900/family Deductible amounts applied to charges incurred in the last three months of the calendar year are carried over and applied to the next year's deductible. The deductible doesn't apply to prescription drugs, preventive care or hearing aids.	$500/person; $1,500/family Deductible amounts applied to charges incurred in the last three months of the calendar year are carried over and applied to the next year's deductible. The deductible doesn't apply to prescription drugs, preventive care or hearing aids.
Copays	Applicable only to emergency room care and prescription drugs (See "Covered Expenses" for amounts)
After the deductible/copays, the plan pays most covered services at these levels until you reach the annual out-of-pocket maximum	Network: 90% (You pay 10% coinsurance) Out-of-network: 70% (You pay 30% coinsurance) 100% of network rate after applicable copays for prescription drug claims (Deductible doesn't apply)	Network: 80% (You pay 20% coinsurance) Out-of-network: 60% (You pay 40% coinsurance) 100% of network rate after applicable copays for prescription drug claims (Deductible doesn't apply)	Network: 80% (You pay 20% coinsurance) Out-of-network: 60% (You pay 40% coinsurance) 100% of network rate after applicable copays for prescription drug claims (Deductible doesn't apply)
Annual out-of-pocket maximum	Network: $800/person or $1,600/family, plus deductible Out-of-network: $1,600/person or $3,200/family, plus deductible Doesn't apply to prescriptions (See "Annual Out-of-Pocket Maximum" for details)	Network: $1,000/ person or $2,000/ family, plus deductible Out-of-network: $1,800/ person or $3,600/ family, plus deductible Doesn't apply to prescriptions (See "Annual Out-of-Pocket Maximum" for details)	Network: $1,200/ person or $2,400/ family, plus deductible Out-of-network: $2,000/person or $4,000/family, plus deductible Doesn't apply to prescriptions (See "Annual Out-of-Pocket Maximum" for details)
After you reach the out-of-pocket maximum, most benefits are paid for the rest of the calendar year at this level	Network: 100% Out-of-network: 100% of R&C charges
Lifetime maximum	$2,000,000	$2,000,000	$2,000,000

Covered Expenses

The following table summarizes covered services and supplies under KingCare^SM (only medically necessary services, prescription drugs and supplies are covered) and identifies related coinsurance, copays, maximums and limits. (For more details, see "Knowing What's Covered and What's Not.")

IMPORTANT!

Aetna processes medical claims; Express Scripts processes outpatient, retail pharmacy and mail-order prescription drug claims. Where a benefit involves claims processed by both Aetna and Express Scripts, you'll find information in the following table or under "Covered Expenses."


Covered Expenses	KingCare^SM Gold	KingCare^SM Silver	KingCare^SM Bronze
Alternative care (including medically necessary acupuncture, hypnotherapy and massage therapy)	Network: 90% Out-of-network: 70% Massage services must be prescribed by a physician. A total of 60 covered visits/year (may include any combination of acupuncture, hypnotherapy and/or massage therapy visits)	Network: 80% Out-of-network: 60% Massage services must be prescribed by a physician. A total of 60 covered visits/year (may include any combination of acupuncture, hypnotherapy and/or massage therapy visits)	Network: 80% Out-of-network: 60% Massage services must be prescribed by a physician. A total of 60 covered visits/year (may include any combination of acupuncture, hypnotherapy and/or massage therapy visits)
Ambulance services	90%	80%	80%
Chemical dependency treatment (requires preauthorization)	Network: 100% Out-of-network: 70% Up to $15,000 in 24 consecutive months for combined network and out-of-network services (maximum subject to annual adjustment)	Network: 80% Out-of-network: 60% Up to $15,000 in 24 consecutive months for combined network and out-of-network services (maximum subject to annual adjustment)	Network: 80% Out-of-network: 60% Up to $15,000 in 24 consecutive months for combined network and out-of-network services (maximum subject to annual adjustment)
Chiropractic care and manipulative therapy (like all services, must be medically necessary)	Network: 90% Out-of-network: 70% Up to 33 visits/year for combined network and out-of-network services Limited to diagnosis and treatment of musculoskeletal disorders	Network: 80% Out-of-network: 60% Up to 33 visits/year for combined network and out-of-network services Limited to diagnosis and treatment of musculoskeletal disorders	Network: 80% Out-of-network: 60% Up to 33 visits/year for combined network and out-of-network services Limited to diagnosis and treatment of musculoskeletal disorders
Diabetes care training	Network: 90% when prescribed by your physician Out-of-network: 70% when prescribed by your physician	Network: 80% when prescribed by your physician Out-of-network: 60% when prescribed by your physician	Network: 80% when prescribed by your physician Out-of-network: 60% when prescribed by your physician
Diabetes supplies (insulin, needles, syringes, lancets, etc.)	Covered under prescription drugs
Durable medical equipment, prosthetics and orthopedic appliances	80% when preauthorized
Emergency room care (Also see "Urgent Care")	Emergency care, network or out-of-network: 90% after $100 copay/visit (waived if admitted) Non-emergency care, network or out-of-network: 70% after $100 copay/visit	Emergency care, network or out-of-network: 80% after $100 copay/visit (waived if admitted) Non-emergency care, network or out-of-network: 60% after $100 copay/visit	Emergency care, network or out-of-network: 80% after $100 copay/visit (waived if admitted) Non-emergency care, network or out-of-network: 60% after $100 copay/visit
Family planning	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Growth hormones	Network: 90% when preauthorized Out-of-network: 70% when preauthorized May also be covered under the prescription drug benefit (See "Using Your Prescription Drug Plan")	Network: 80% when preauthorized Out-of-network: 60% when preauthorized May also be covered under the prescription drug benefit (See "Using Your Prescription Drug Plan")	Network: 80% when preauthorized Out-of-network: 60% when preauthorized May also be covered under the prescription drug benefit (See "Using Your Prescription Drug Plan")
Hearing aids	100%, up to $500 in 36 months for combined network and out-of-network services Deductible doesn't apply
Home health care	100% when preauthorized, up to 130 visits/year for combined network and out-of-network services
Hospice care	100% when preauthorized 6-month lifetime maximum 120-hour maximum for respite care in any 3-month period
Hospital care	Network: 90% when preauthorized Out-of-network: 70% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized
Infertility	Network: 90% Out-of-network: 70% Limited to specific services and $25,000 lifetime maximum for combined network and out-of-network services	Network: 80% Out-of-network: 60% Limited to specific services and $25,000 lifetime maximum for combined network and out-of-network services	Network: 80% Out-of-network: 60% Limited to specific services and $25,000 lifetime maximum for combined network and out-of-network services
Injury to teeth	Network: 90% Out-of-network: 70% Up to $600/accident for combined network and out-of-network services	Network: 80% Out-of-network: 60% Up to $600/accident for combined network and out-of-network services	Network: 80% Out-of-network: 60% Up to $600/accident for combined network and out-of-network services
Inpatient care alternatives	Network: 90% when preauthorized Out-of-network: 70% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized
Jaw abnormalities, or malocclusions (covered when medically necessary)	Network: 90% when preauthorized Out-of-network: 70% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized
Lab, X-ray and other diagnostic testing	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Maternity care	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Mental health care (when deemed appropriate, 2 unused outpatient visits may be traded for 1 inpatient day, or vice versa; requires preauthorization)	Network: 90% Out-of-network: 70% For inpatient care: Up to 30 days/year; combined network and out-of-network services For outpatient care: Up to 52 visits/year; combined network and out-of-network services	Network: 80% Out-of-network: 60% For inpatient care: Up to 30 days/year; combined network and out-of-network services For outpatient care: Up to 52 visits/year; combined network and out-of-network services	Network: 80% Out-of-network: 60% For inpatient care: Up to 30 days/year; combined network and out-of-network services For outpatient care: Up to 52 visits/year; combined network and out-of-network services
Naturopathy	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Neurodevelopmental therapy for dependents age 6 and under	Network: 90% when preauthorized Out-of-network: 70% when preauthorized Up to $2,000/year for combined network and out-of-network services	Network: 80% when preauthorized Out-of-network: 60% when preauthorized Up to $2,000/year for combined network and out-of-network services	Network: 80% when preauthorized Out-of-network: 60% when preauthorized Up to $2,000/year for combined network and out-of-network services
Obesity surgery or other procedures, treatment or services, such as gastric intestinal bypass surgery	Network: 90% when preauthorized and medically necessary Out-of-network: 70% when preauthorized and medically necessary Successful completion of a physician-supervised weight management and exercise program required before preauthorization.	Network: 80% when preauthorized and medically necessary Out-of-network: 60% when preauthorized and medically necessary Successful completion of a physician-supervised weight management and exercise program required before preauthorization.	Network: 80% when preauthorized and medically necessary Out-of-network: 60% when preauthorized and medically necessary Successful completion of a physician-supervised weight management and exercise program required before preauthorization.
Out-of-area coverage—for example, while traveling or for your children away at school	Same coverage as when home, through Aetna and Express Scripts national provider networks
Phenylketonuria (PKU) formula	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Physician and other medical/surgical services	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Prescription drugs—Up to a 30-day supply through network pharmacies	Generic: 100% after $10 copay Preferred brand: 100% after $15 copay ($20 if generic is available; but if you're unable to take it for medical reasons, the $15 copay applies) Non-preferred brand: 100% after $25 copay ($30 if generic is available; but if you're unable to take it for medical reasons, the $25 copay applies) Prescriptions filled at out-of-network pharmacies are reimbursed at the rate Express Scripts pays to network pharmacies, less your copay
Prescription drugs—Up to a 90-day supply through mail-order network only	Generic: 100% after $20 copay Preferred brand: 100% after $30 copay ($40 if generic is available; but if you're unable to take it for medical reasons, the $30 copay applies) Non-preferred brand: 100% after $50 copay ($60 if generic is available; but if you're unable to take it for medical reasons, the $50 copay applies)
Preventive care (well-child check-ups, immunizations, routine health and hearing exams, etc.)	Network: 100% Out-of-network: 70% Deductible doesn't apply	Network: 100% Out-of-network: 60% Deductible doesn't apply	Network: 100% Out-of-network: 60% Deductible doesn't apply
Radiation therapy, chemotherapy and respiratory therapy	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Reconstructive services (includes benefits for mastectomy-related services; reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from mastectomy, including lymphedema) Call plan for more information.	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%
Rehabilitative services—Inpatient and outpatient	Network: 90% Out-of-network: 70% Inpatient: Up to 60 days/year Outpatient: Up to 60 visits/all therapies combined (progress review every 20 visits for out-of-network outpatient)	Network: 80% Out-of-network: 60% Inpatient: Up to 60 days/year Outpatient: Up to 60 visits/all therapies combined (progress review every 20 visits for out-of-network outpatient)	Network: 80% Out-of-network: 60% Inpatient: Up to 60 days/year Outpatient: Up to 60 visits/all therapies combined (progress review every 20 visits for out-of-network outpatient)
Skilled nursing facility	Network: 90% when preauthorized Out-of-network: 70% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized	Network: 80% when preauthorized Out-of-network: 60% when preauthorized
Smoking cessation	Network: 100% Out-of-network: 70% Prescription drugs to ease nicotine withdrawal, inhalers and sprays are covered by Express Scripts at 100% (no copay); non-prescription nicotine patches, lozenges and gum are covered by Aetna at 100%.	Network: 100% Out-of-network: 60% Prescription drugs to ease nicotine withdrawal, inhalers and sprays are covered by Express Scripts at 100% (no copay); non-prescription nicotine patches, lozenges and gum are covered by Aetna at 100%.	Network: 100% Out-of-network: 60% Prescription drugs to ease nicotine withdrawal, inhalers and sprays are covered by Express Scripts at 100% (no copay); non-prescription nicotine patches, lozenges and gum are covered by Aetna at 100%.
Temporomandibular joint (TMJ) disorders	Network: 90% when preauthorized Out-of-network: 70% when preauthorized Night guards are covered if prescribed by a medical doctor for a TMJ disorder. Up to $2,000/year for combined network and out-of-network services	Network: 80% when preauthorized Out-of-network: 60% when preauthorized Night guards are covered if prescribed by a medical doctor for a TMJ disorder. Up to $2,000/year for combined network and out-of-network services	Network: 80% when preauthorized Out-of-network: 60% when preauthorized Night guards are covered if prescribed by a medical doctor for a TMJ disorder. Up to $2,000/year for combined network and out-of-network services
Transplants (certain services only)	Network: 100% when preauthorized Out-of-network: 70% when preauthorized Medical coverage must have been continuous for more than 12 months under KingCare^SM before a transplant will be covered.	Network: 100% when preauthorized Out-of-network: 60% when preauthorized Medical coverage must have been continuous for more than 12 months under KingCare^SM before a transplant will be covered.	Network: 100% when preauthorized Out-of-network: 60% when preauthorized Medical coverage must have been continuous for more than 12 months under KingCare^SM before a transplant will be covered.
Urgent care (ear infections, high fevers, minor burns, etc.)	Network: 90% Out-of-network: 70%	Network: 80% Out-of-network: 60%	Network: 80% Out-of-network: 60%

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Updated: August 1, 2007

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