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E MPLOYEE CONTRIBUTIONS
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MEDICAL BENEFITS DESCRIPTION
B E N E F I T S P L A N O V E R V I E W P A G E 2
Aetna IH & Non-IH
PPO 1500 HSA
Employee
Bi-Monthly
Cost
Employee Only $27.76
Employee + Spouse $261.14
Employee + Child(ren) $233.70
Family $429.10
Dental
Employee
Bi-Monthly
Cost
Employee Only $0.00
Employee + Spouse $15.51
Employee + Child(ren) $22.97
Family $42.74
Vision
Employee
Bi-Monthly
Cost
Employee Only $0.00
Employee + Spouse $4.04
Employee + Child(ren) $2.80
Family $7.23
Aetna IH & Non-IH
Open HMO 2500 HSA
Employee
Bi-Monthly
Cost
Employee Only $13.40
Employee + Spouse $119.35
Employee + Child(ren) $89.10
Family $239.25
Plan Design Aetna IH & Non-IH Aetna IH & Non-IH
PPO 1500 HSA Open HMO 2500 HSA
Deductible (Policy Year): In Network Out of Network In Network Only
- Single $1,500 $3,000 $2,500
- Family $3,000 $6,000 $5,000
Out of Pocket Maximum (Policy Year):
- Single $3,000 $6,000 $5,000
- Family $6,000 $12,000 $6,850
Coinsurance: Copays 70% / 30% Allowed
Benefit
Copays
Office Visits: Deductible First, then; Deductible First, then;
- Primary Care Physician $20 Copay 30% Allowed Benefit $30 Copay
- Specialist $40 Copay 30% Allowed Benefit $50 Copay
- Lab and x-ray (free standing) $40 Copay 30% Allowed Benefit $50 Copay
Routine Coverage:
- Well Baby Covered in Full 30% Allowed Benefit Covered in Full
- Adult Covered in Full 30% Allowed Benefit Covered in Full
Deductible waived for Preventive
Hospitalization: Deductible First, then; Deductible First, then;
- Inpatient $500 / Admission 30% Allowed Benefit $300 copay per day to a max
copay of $1500 per
admission
- Outpatient $300 Copay 30% Allowed Benefit $200 Copay
- Accident/Medical Emergency $200 Copay Same as In network $200 Copay
- Urgent Care $75 Copay 30% Allowed Benefit $75 Copay
Prescription Drugs: Integrated medical and rx Integrated medical and rx
- Generic $10 Copay $10 Copay
- Brand (Formulary) $35 Copay $35 Copay
- Brand (Non-Formulary) $60 Copay $60 Copay
- Specialty Drugs $200 Copay $200 Copay
- Mail Order 2 x Copay 2 x Copay
Lifetime Maximum Unlimited Unlimited