Additional Voluntary Coverages
Learn more about the additional voluntary coverages available to you
Looking for more details?
You can access more detailed coverage information (posted in the Reference Center) on MyBenefits Online.
Benefits Made Right
Auto and Homeowners Insurance provides discounted coverage for your car and home, and includes renters and liability insurance. You pay for coverage via after-tax payroll deductions, which are remitted to Mercer. See the attached for an overview of this coverage, and visit www.mondelezvoluntarybenefits.com for more details.
Identity Theft Protection through Allstate Identity Protection (AIP) helps keep your personal information and identity safe. You pay for this coverage on an after-tax basis via payroll deductions. For more information, visit www.infoarmor.com.
Key coverage features include:
You can access more detailed coverage information (posted in the Reference Center) on MyBenefits Online.
| Features | Outside the U.S. | In the U.S. | |
|---|---|---|---|
| Preferred Benefits (In-Network) | Non-Preferred Benefits (Out-of-Network) | ||
| Individual Deductible | $0 per calendar year | $700 per calendar year | $1,350 per calendar year |
| Family Deductible | $0 per calendar year | $1,400 per calendar year | $2,700 per calendar year |
| Prior Plan Credit | Does not apply | ||
| Individual Coinsurance Limit | $0 per calendar year | $3,000 per calendar year | $6,000 per calendar year |
| Does not include deductibles, copays, benefit penalties, 50% items, and Outpatient Prescription Drugs; includes Outpatient Prescription Drugs when outside the U.S. | |||
| Family Coinsurance Limit | $0 per calendar year | $6,000 per calendar year | $12,000 per calendar year |
| Does not include deductibles, copays, benefit penalties, 50% items, and Outpatient Prescription Drugs; includes Outpatient Prescription Drugs when outside the U.S. | |||
| Lifetime Maximum | Unlimited | ||
| Member Payment Percentages | |||
| Hospital Services | |||
| Inpatient | No charge | 20% after deductible | 40% after deductible |
| Outpatient | No charge | 20% after deductible | 40% after deductible |
| Private Room Limit | The institution’s semiprivate rate | ||
| Pre-certification Penalty | No penalty | No penalty | $400 |
| To avoid penalties and/or benefit reductions for non-preferred benefits received in the U.S., contact the service center to determine if precertification is needed for a procedure. | |||
| Non-Emergency Use of the Emergency Room | No penalty | 50% after deductible | 50% after deductible |
| Emergency Room | No charge | 20% after deductible | 20% after deductible |
| Non-Urgent Use of Urgent Care Provider | No charge | 20% after deductible | 40% after deductible |
| Urgent Care | No charge | 20% after deductible | 40% after deductible |
| Ambulance | No charge | 20% after deductible | 40% after deductible |
| Physician Services | |||
| Physician Office Visit | No charge | 20% after deductible | 40% after deductible |
| Specialist Office Visit | No charge | 20% after deductible | 40% after deductible |
| Virtual Care and Virtual Primary Care | Not covered | No charge | Not covered |
| Walk-in Clinics | No charge | 20% after deductible | 40% after deductible |
| Designated Walk-in Clinics, no charge when outside the U.S. Walk-in Clinics are free-standing health care facilities that (a) may be located in or with a pharmacy, drug store, supermarket, or other retail store, and (b) provide limited medical care and services on a scheduled or unscheduled basis. Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers, and physician offices are not considered to be a Walk-in Clinic. | |||
| Mental Health Services* | |||
| Mental Health Inpatient Coverage (Unlimited days per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Mental Health Outpatient Coverage (Unlimited visits per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Alcohol/Drug Abuse Services* | |||
| Substance Abuse Inpatient Coverage (Unlimited days per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Substance Abuse Outpatient Coverage (Unlimited visits per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Other Services | |||
| Skilled Nursing Facility (120 days per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Hospice Care Facility Inpatient (60 days lifetime maximum) | No charge | 20% after deductible | 40% after deductible |
| Hospice Care Facility Outpatient (Unlimited lifetime maximum) | No charge | 20% after deductible | 40% after deductible |
| Home Health Care (120 visits per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Private Duty Nursing (70 shifts per calendar year) | No charge | 20% after deductible | 40% after deductible |
| Spinal Disorder Treatment (Unlimited visits per calendar year) | No charge | 20% after deductible | 25% after deductible |
| Short-Term Rehabilitation | No charge | 20% after deductible | 25% after deductible |
| Includes coverage for Occupational and Physical Therapies; unlimited visits per calendar year. | |||
| Speech Therapy | No charge | 20% after deductible | 40% after deductible |
| Includes coverage for Speech Therapies; 60 visits per calendar year. | |||
| Diagnostic Outpatient X-ray | No charge | 20% after deductible | 40% after deductible |
| Diagnostic Outpatient Lab | No charge | 20% after deductible | 40% after deductible |
| Bariatric Surgery (Unlimited per lifetime) | No charge | 20% after deductible | 40% after deductible |
| Base Infertility Services | No charge | 20% after deductible | 40% after deductible |
| Base plan coverage is limited to the testing and treatment of an underlying condition. | |||
| Other Services | |||
| Comprehensive Infertility Services | No charge | 20% after deductible | 40% after deductible |
| Six cycles of Comprehensive plan coverage include coverage of Artificial Insemination and Ovulation Induction. | |||
| ART Infertility Services | No charge | 20% after deductible | 40% after deductible |
| Six cycles per lifetime for Advanced Reproductive Technology (ART) coverage with cryopreservation, storage, and unlimited embryo transfers. | |||
| Autism | Autism covered same as any other expenseMember cost sharing is based on the type of service performed and the place of service where it is rendered. | ||
| Payment for Non-Preferred Providers** | Not applicable | Not applicable | Professional: 105% of MedicareFacility: 140% of Medicare |
| Routine Hearing Exam (Includes one routine exam every 12 months.) | No charge | No charge | 40% after deductible |
| Hearing Aids | No charge | 20% after deductible | 40% after deductible |
| One hearing aid per ear, up to $1,000 maximum per ear every three years, for child to age 24. | |||
| Aetna Assistance Program (Unlimited calendar year maximum) | No charge | No charge | No charge |
| Employee Assistance Program (EAP) | Included | Included | Included |
| Includes up to five counseling sessions per issue, per year, per enrolled member. Access benefits by calling the member service number on ID card: 1-800-231-7729 or collect 1-813-775-0190. Services include: cultural adjustment assistance, marital/family stress, child care and behavioral concerns, social adaptation needs, alcohol/substance abuse, work/life balance, and depression. | |||
| Wellness Benefits | |||
| Routine Children Physical Exams | No charge | No charge | No charge |
| Seven exams in the first 12 months of life, three exams in the second 12 months of life, three exams in the third 12 months of life, one exam per 12 months thereafter to age 22 (includes immunizations). | |||
| Routine Adult Physical Exams | No charge | No charge | No charge up to a $1,000 calendar-year maximum (includes immunizations, X-rays, and labs) |
| Adults age 22+ & -65: one exam/12 months; Adults age 65+: one exam/12 months (includes immunizations). | |||
| Routine Gynecological Exams | No charge | No charge | No charge |
| Includes one exam and pap smear per calendar year. | |||
| Mammograms (Unlimited visits per calendar year) | No charge | No charge | No charge |
| Prostate Specific Antigen (PSA) (Unlimited visits per calendar year) | No charge | No charge | No charge |
| Digital Rectal Exam (DRE) (Unlimited visits per calendar year) | No charge | No charge | No charge |
| Cancer Screening | No charge | No charge | No charge |
| Recommended: Members age 45 and older. | |||
| Prescription Drug Coverage | |||
| Generic Drugs (365-day maximum supply) | No charge | $10 copay per month supply (includes Mail Order Drugs) | 40% no deductible |
| Brand Name Drugs (365-day maximum supply) | No charge | $20 copay per month supply (includes Mail Order Drugs) | 40% no deductible |
| Vision Expenses | |||
| Routine Eye Exam | No charge | No charge | No charge up to a maximum of $35 after $10 per-visit deductible |
| Covered under medical. Includes one routine exam per calendar year. | |||
| Single, Bifocal, Trifocal & Lenticular Vision Lenses (Two lenses, once every calendar year) | No charge | No charge | No charge |
| Frames-Retail (Once every other calendar year) | No charge up to $100 | No charge up to $100 | No charge up to $100 |
| Contact Lenses (In place of lens and frame allowances, once every calendar year) | No charge up to $110 | No charge up to $110 | No charge up to $110 |
| Comprehensive Dental | |||
| Calendar Year Deductible | $50 per calendar year | ||
| Family Deductible | $150 per calendar year | ||
| Type A Expense (Diagnostic & Preventative) | No charge | ||
| Type B Expense (Basic Restorative) | 20% after deductible | ||
| Type C Expense (Major Restorative) | 50% after deductible | ||
| Type D Expense (Major Restorative) | 50% after deductible | ||
| Orthodontic Treatment (Dependent children only) | 50% after deductible | ||
| Calendar Year Maximum | $2,000 | ||
| Orthodontic Lifetime Maximum | $2,000 | ||
| TMJ Lifetime Maximum | $1,200 | ||
| Implants Calendar Year Maximum | $2,000 | ||
| Services and Programs Included in Quote | |||
| Informed Health Line (24-hour nurse line) | International Maternity Management Program | ||
| International Case Management | Well-Being Assessment | ||
| *This Plan includes coverage under the extent required in accordance with the Federal Mental Health Parity and Addiction Equity Act (MHPAEA), beginning with plan years starting on or after January 1, 2018. ** Payment for Non-Preferred Providers: We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are “in-network” or “out-of-network.” | |||
Log in to MyBenefits Online to view your current coverage and plan details.
| This Plan includes coverage for women’s preventive health benefits, to the extent required under U.S. federal law effective beginning with plan years starting on or after August 1, 2012. |
| Payment limits apply per individual on a calendar-year basis. Only those out-of-pocket expenses resulting from the application of a payment percentage may be used to satisfy the payment limit. Deductibles, copays, benefit penalties, and 50% items are excluded from the payment limit. |
| Cross-application applies to your calendar-year deductible requirement, out-of-pocket maximum, and lifetime maximum when you receive both in-network and out-of-network covered services. |
| Coverage maximums, up to a certain number of days/visits per calendar year, are reached by combining the preferred and non-preferred benefits (up to the limit for either one, but not both). (Example: If the preferred benefit is for 120 days and the non-preferred benefit is for 120 days, the maximum benefit is 120 days, not 240 days.) |
| Maternity expenses are covered as any other covered medical expense. Coverage is provided for an eligible employee, spouse, and all eligible female family members. Pregnancy benefits do not continue to be payable after coverage ends, except in the event of total disability. |
| For contracted hospitals—non-contracted Radiologists, Anesthesiologists, and Pathologists (RAPS) are paid at the preferred level, and will be subject to reasonable and customary charges. Note that this payment method may apply to other providers. |
| Other Health Care (Out-of-Area): When care is provided in the U.S. in a geographic area in which Aetna has not contracted with a provider, charges are payable at 80% after any applicable deductible requirement (does not apply to those expenses paid at a reduced payment percentage). The benefit levels associated with the following in-network provisions would apply:
Deductible, Family Deductible, Inpatient Hospital Deductible, Out-of-Pocket Maximum(s). |
| This Plan includes coverage under the extent required in accordance with the Federal Mental Health Parity and Addiction Equity Act (MHPAEA), beginning with plan years starting on or after January 1, 2018. |
| Payment for Non-Preferred Providers
We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are “in-network” or “out-of-network.” We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you’ll need to pay for this out-of-network care. |
| As an example, you may choose a doctor in our network, or you may choose to visit an out-of-network doctor. If you choose a doctor who’s outside the network, your Aetna health plan may pay some of that doctor’s bill. Most of the time, you’ll pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. |
| When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When you choose out-of-network care, Aetna “recognizes” an amount based on what Medicare pays for these services. The government sets the Medicare rate. Exactly how much Aetna “recognizes” depends on the coverage you or your employer selects. |
| Your out-of-network doctor sets the rate to charge you. It may be higher—sometimes much higher—than what your Aetna coverage “recognizes” or “allows.” Your doctor may bill you for the dollar amount that Aetna doesn’t recognize. You must also pay any required copayments, coinsurance, and deductibles under your Plan. No dollar amount above the recognized charge counts toward your deductible or maximum out-of-pocket. To learn more about how the Plan pays out-of-network benefits, visit www.aetna.com. Type “how Aetna pays” in the search box. |
| You can avoid these extra costs by getting your care from Aetna’s broad network of health care providers. Go to www.aetna.com and select “Find a Doctor” on the left side of the page. If you’re already a member, sign on to your Aetna Navigator member site. |
| This way of paying out-of-network doctors and hospitals applies when you choose to get care outside the network. When you don’t have a choice (for example: an emergency room visit after a car accident), the Plan will pay the bill as if you received in-network care. You pay your required copayments, coinsurance, and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You’re not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance, and deductibles. |
| Benefit maximums per calendar year are calculated between January 1 and December 31. |
Pre-Existing Conditions:
|
| Plan 2804: |
| Dental Indemnity |
| Type A Includes prophylaxis, bitewing and full-mouth series X-rays, space maintainers, oral exams, fluoride applications, sealants, and periapical X-rays. |
| Type B Includes fillings, simple extractions, and oral surgery. |
| Type C Includes crown lengthening, crown buildup, inlays/onlays, bridgework, osseous surgery, soft tissue grafts, partial and full bony impactions, general anesthesia and intravenous sedation, dentures (benefit includes all relines, rebases, and adjustments within six months of installation), molar root canal therapy, prosthetic repairs, and occlusal guards (for bruxism only). |
Note: This is not evidence of coverage. You must enroll and be accepted for coverage with the Coverage Administrator before these documents will be effective. In the case of a discrepancy between the Plan documents and this material, the Plan documents will determine the Plan of Benefits. As used herein, the term “Plan documents” includes, but is not limited to, the Employee Booklet, Summary of Coverage, and any Employee Booklet Amendments/Riders (including any state-specific variations), as applicable. For further details, refer to your Plan documents. |
| The proposed Plan of Benefits is underwritten by Aetna Life Insurance Company (Delaware). |
| This is only a brief summary of the PPO Medical and Comprehensive PPO Dental benefits available. Some restrictions may apply. |
| For more specific information about the coverage details, including limitations, exclusions, and other plan requirements, please refer to the Employee Booklet. |
You can access more detailed information on MyBenefits Online.