CAPABILITY OVERVIEW

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8 Tonganoxie USD #464
Throug you will have
the ability to:
 Find Doctors & Hospitals
 Check Claim Status
 Order New ID Card
 View Benefits
 Access Prescription Drug List
Medical Plan
Tonganoxie UDS#464 offers three medical plan options for you to choose
from. The benefits you elect now will be effective October, 2017 –
September 30, 2018.
We recommended that you visi or call 1-800-238-6716 to
see if your provider is in the Aetna Network.
The Medical Plan chart below is for illustrative purposes only and does not
include all benefits, plan limitations, and/or exclusions. This represents in-
network benefits only. Please refer to the Aetna summary for greater detail.
In the event there is a discrepancy in benefits, the carrier benefit
summary/SPD will always govern.
QHDHP BASE PPO BUY-UP PPO
Deductible
- Individual
- Family
$2,700
$5,400
$2,000
$4,000
$1,500
$3,000
Coinsurance 0% 50% 30%
Out of Pocket (OOP) Max
- Individual
- Family
$3,500
$7,000 $5,000
$10,000
$6,000
$12,000
Physician Office Visits
- PCP
- Specialist
Subject to Ded.
Subject to Ded.
$40
$40
$25
$50
Hospital Services
- Inpatient
- Outpatient surgical
Subject to Ded.
Subject to Ded.
Ded. then 50%
Ded. then 50%
Ded. then 30%
Ded. then 30%
Emergency Room
Urgent Care
Subject to Ded.
Subject to Ded.
Deductible then $200 copay
$50
Deductible then $200 copay
$50
Prescription Drugs
- Deductible
- Tier 1A
- Tier 1
- Tier 2
- Tier 3
- Tier 4
Preferred
Non-Preferred
Deductible then copays
$3
$12
$50
$75
20% up to $150
20% up to $250
N/A
$3
$12
$40
$65
20% up to $150
20% up to $250
N/A
$3
$12
$40
$65
20% up to $150
20% up to $250