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P A G E 2
Medical Benefits Description
B E N E F I T S P L A N O V E R V I E W
Benefits Description
Aetna HNO Only
Aetna HNO HSA Comp
In-Network
Out-Of-Network
In-Network
Out-Of-Network
Employer Contribution to
Health Savings Account
N/A
N/A
$185 (pro-rated)
Lifetime Maximum
Unlimited
Unlimited
Out-Of-Pocket Maximum
Individual
Family
$4,000
$8,000
N/A
N/A
$3,000
$6,000
N/A
N/A
Deductible
Individual
Family
$1,000
$2,000
N/A
N/A
$1,500
$3,000
N/A
N/A
Coinsurance
80% / 20%
N/A
100% / 0%
N/A
Preventive Care
Covered in full
Not covered
Covered in full
Not covered
Primary Office Visit
$30 copay
Not covered
$20 copay after deductible
Not covered
Specialist Services
$50 copay
Not covered
$30 copay after deductible
Not covered
Emergency Room
$150 copay
(waived if admitted)
Paid as In-Network
$150 copay after deductible
Paid as In-Network
Inpatient Hospital
Services
20% after deductible
Not covered
$250 copay per admission
after deductible
Not covered
Outpatient Surgery
20% after deductible
Not covered
Covered in full after
deductible
Not covered
Lab & Pathology
Services
Covered in full
Not covered
$30 copay after deductible
Not covered
X-Ray Services
Routine Radiology/Diagnostic
MRI/MRA, CT, PET Scans
$50 copay
$100 copay
Not covered
Not covered
$30 copay after deductible
$100 copay after deductible
Not covered
Not covered
Routine Mammography
Covered in full
Not covered
Covered in full
Not covered
Routine Eye Exam
(once every year)
Covered in full
Not covered
Covered in full
Not covered
Durable Medical Equipment
20%
Not covered
20% after deductible
Not covered
Prescription Drug
(including oral contraceptives)
Generic
Brand
Formulary
Mail Order (2x retail)
$15 copay
$35 copay
$60 copay
$30 / $70 / $120 copay
Not covered
Not covered
Not covered
Not covered
$15 copay
$35 copay
$60 copay
$30 / $70 / $120 copay
Not covered
Not covered
Not covered
Not covered
A Health Savings Account (HSA) is a savings account
used for setting aside pre-tax dollars in order to pay for
qualified medical, dental, or vision expenses.
The HSA account is located at Wells Fargo Bank. The
account earns interest and may incur fees.
To open an HSA, you must participate in Aetna's HNO
HSA Compatible Plan.
If you open an HSA while at CenterStage, the company
makes an annual contribution to the account. This amount
is $185.00 (prorated).
For calendar year 2016, the maximum you can contribute
(through payroll deductions) is $3,350 for Individuals and
$6,750 for Families. In 2017, the Single amount increases
to $3,400.
You are the owner of the account. If you leave
CenterStage, the account stays with you. It is always
yours.
You cannot contribute to both a Medical FSA and an HSA
Health Savings Account in the same year. You cannot
contribute to an HSA if you have a balance in a
Healthcare FSA. See other limitations and more details at
the website below:
www.wellsfargo.com/HSAHealth Savings Account (HSA)
*see Aetna benefit summary for more details