2017-2018 Mosaic Overview

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P A G E 3
Each eligible employee will be able to
elect to enroll in the MOSAIC medical
program offered through Aetna. Please
refer to the following pages for an overview of the medical program.
To find a provider, go to and utilize the “Find
a Physician” feature, or call the Member Services number on your ID
card for a list of providers nearest you. When searching online, elect
PPO “Managed Choice POS (Open Access)” or HMO “Aetna
Health Network Only (Open Access)”.
Employer HRA Contribution
Enrollment Tier Contribution
Employee $3,500.00
Employee/Spouse $7,000.00
Employee/Child(ren) $7,000.00
Family $7,000.00
Medical Benefits
Employee Payroll Deductions
(per pay)
Enrollment Tier Deduction
Employee $0.00
Employee/Spouse $79.00
Employee/Child(ren) $45.00
Family $100.00
Benefit Aetna Managed Choice POS
(Open Access)
Aetna
(HNOnly Open Access HMO)
In-Network Out-of-Network In-Network
Annual Deductible
Individual
Family
Coinsurance
$4,000
$8,000
80%
$8,000
$16,000
60%
$4,000
$8,000
80%
Annual Out-of-Pocket Maximum
Individual
Family
$6,350
$12,700
$14,000
$28,000
$6,350
$12,700
Office Visits
Primary Care Physician
Specialist
Deductible, then 20%
Deductible, then 20%
Deductible, then 40%
Deductible, then 40%
Ded, then $30 copay
Ded, then $30 copay
Hospitalization
In-Patient
Out-Patient
Lab & X-Rays
Accident/Medical Emergency Room
Urgent Care
Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Deductible, then 40%
Deductible, then 40%
Deductible, then 40%
Deductible, then 40%
Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Deductible, then 20%
Prescription Drugs
Retail Co-Payment
Copays (Gen/Brand/Pref)
Provider Network
Medical and RX Ded. Combined
$20/$60/$100
Medical and RX Ded. Combined
$20/$60/$100
Employee Payroll Deductions
(per pay)
Enrollment Tier Deduction
Employee $25.00
Employee/Spouse $161.00
Employee/Child(ren) $80.00
Family $193.00
Ded, then 20%