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Medical Plan Comparison
Benefit Provision
Aetna HMO
Gold Plan
Aetna HMO
Silver Plan
Aetna Open Access
Managed Choice Plan (OAMC)
Network
Non-Network
Deductible (calendar year)
None
None
$250 individual/$500 family
Out-Of-Pocket Maximum
(calendar year)
$1,000 individual
$2,000 family max
$1,000 individual
$2,000 family max
$1,000 individual
$2,000 family max
$3,000 individual
$6,000 family max
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Preventive Benefits
Annual Routine Physical
100% covered
100% covered
100% covered
Well Baby Immunizations
100% covered
100% covered
100% covered
Physician Services
Office Visit
$10 copay
$20 copay
$15 copay
30%
Specialist
$20 copay
$30 copay
$20 copay
30%
Diagnostic X-ray
$20 copay
$30 copay
10% copay
30%
Maternity/OB Visits
$10 copay
(initial visit only)
$20 copay
(initial visit only)
$20 copay
(initial visit only)
30%
Hospital Services
Inpatient Surgery
100% covered $500 copay (per admit)
10%
30%
Outpatient Surgery
100% covered $250 copay (per surgery)
10%
30%
Detoxification
Outpatient: $20 copay
Inpatient: No charge
Outpatient: $30 copay
Inpatient: $500 copay
(per admit)
10%
30%
Other Benefits
Emergency Services
$150 copay
$150 copay
$75 copay; no deductible
Urgent Care
$35 copay; PCP referral $35 copay; PCP referral
$15 copay
30%
Ambulance
No charge
No charge
10%
Durable Medical Equipment 20% of contracted amt 20% of contracted amt
10%
30%
Chiropractic
$15 copay;
30 visits/year
$15 copay;
30 visits/year
$20 copay
30%
20 visits/year combined
Vision Services
Annual Exam & Refraction
100%
100%
100%
30%
Prescription Drugs Through Catamaran
Retail (30-day supply)
OTC*
$0 copay
$0 copay
$0 copay
Coverage at network
pharmacies only
Generic
$10 copay
$10 copay
$10 copay
Preferred Brand**
$25 copay
$25 copay
$25 copay
Non-Preferred Brand**
$50 copay
$50 copay
$50 copay
Specialty Pharmacy
$50 copay
$50 copay
$50 copay
Retail 90 (84-90 day supply)
OTC*
$0 copay
$0 copay
$0 copay
Coverage at network
pharmacies only
Generic
$20 copay
$20 copay
$20 copay
Preferred Brand**
$50 copay
$50 copay
$50 copay
Non-Preferred Brand**
$100 copay
$100 copay
$100 copay
Mail Order (90-day supply)
OTC*
$0 copay
$0 copay
$0 copay
Coverage at network
pharmacies only
Generic
$20 copay
$20 copay
$20 copay
Preferred Brand**
$50 copay
$50 copay
$50 copay
Non-Preferred Brand**
$100 copay
$100 copay
$100 copay
*Covered Over-the-Counter (OTC) drugs are: Prilosec OTC®; Prevacid® 24HR; Omeprazole OTC; Zegerid OTC and Non-sedating antihistamines (OTC) such as Zyrtec or
(D) cetirizine; Claritin or (D) loratadine; Allegra or (D) fexofenadine in all forms to include chewables and syrups and approved contraceptives . You MUST have a written
prescription from your physician for these drugs to be covered under the plan. In addition, oral generic anti-diabetic medications such as metformin and “certain” generic
high blood pressure medications are available for a $0 copay. **If you or your physician chooses a Brand when a Generic is available, you will pay the difference in price
between the Brand and the Generic PLUS the appropriate Brand copay.
Note
: Branded PPIs such as Nexium, Aciphex, Vimovo and Dexilant are not covered by the plan. Alternatives are lansoprazole, pantoprazole, omeprazole 20mg and 40mg,
and the covered OTCs. Branded non-sedating antihistamines such as Xyzal and Clarinex are also not covered by the plan. Pristiq is excluded.
