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H I
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D U C T I
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UNDERS TAND I NG
YOUR
MEDICAL
PLAN
5
In-Network
Out-of-Network
Overview
Deductible
Individual
$2,000
$5,500
Family Aggregate
$4,000
$11,000
Coinsurance
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Out of Pocket Maximum
Individual
$3,750
$10,500
Family Aggregate
$7,500
$21,000
Lifetime Maximum
Physician's Office Visit
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Preventive Care Services
(Based on age appropiate recommendations)
Plan pays 100%; Deductible waived
Not Covered
Pre-Natal Maternity
Plan pays 100%; Deductible waived Plan Pays 50% after Deductible
Inpatient Maternity Coverage (includes
delivery and postpartum care)
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Inpatient
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Outpatient Hospital Facility
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Emergency Room
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Urgent Care
Plan pays 90% after Deductible
Plan Pays 50% after Deductible
Prescription Drugs
Retail Pharmacy
(30 days)
Generic
$15 Copay after Deductible
Not Covered
Preferred Brand
$50 Copay after Deductible
Not Covered
Non-Preferred
$85 Copay after Deductible
Not Covered
Mail Order Pharmacy
(90 days)
Generic
$37.50 Copay after Deductible
Not Covered
Preferred Brand
$125 Copay after Deductible
Not Covered
Non-Preferred
$212.50 Copay after Deductible
Not Covered
Health Savings Account
Bi-Weekly Contributions
Employee
Employee / Spouse/Domestic Partner
Employee/Child
Employee / Family/Domestic Partner Family
Election of the High Deductible Health Plan entitles you to open a Health Savings Account (HSA) through Optum Bank.
Medical Coverage - Aetna
HSA Qualified High Deductible Plan 90-50
May use both In-Network and Out-of-Network providers
Use Network providers and receive the In-Network level of benefits
Use Non-Network providers receive a lower level of benefits and you may be subject to Balance Billing.
Type of Plan
Includes Deductible, Coinsurance and Copays
If you elect individual coverage, benefits are payable after satisfaction of the $2,000 deductible.
If you elect other than individual coverage, benefits are payable after satisfaction of the $4,000 deductible.
Unlimited
$146.04
$63.93
$178.96
$319.27