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MEDICAL
Plan 1
Plan 2
Plan 3
The Davis Academy
AETNA
AETNA
AETNA
2016 Benefits
POS OAMC 1500 100/70
POS OAMC 2000 80/60
POS OAMC 3500 80/60
NETWORK - OPEN ACCESS
Aetna Managed Choice
Aetna Managed Choice
Aetna Managed Choice
LIFETIME MAXIMUM
Unlimited
Unlimited
Unlimited
IN-NETWORK BENEFITS
CALENDAR YEAR DEDUCTIBLE
SINGLE
$1,500
$2,000
$3,500
FAMILY
$3,000
$4,000
$7,000
COINSURANCE (after deductible)
AETNA
100%
80%
80%
INSURED
0%
20%
20%
OUT-OF-POCKET (OOP):
Includes all Copays, deductibles & coinsurance
SINGLE
$4,000
$6,000
$6,600
FAMILY
$8,000
$12,000
$13,200
PHYSICIAN OFFICE VISIT
PCP COPAY
$25 Copay
$25 Copay
$30 Copay
SPECIALIST COPAY
$50 Copay
$50 Copay
$60 Copay
URGENT CARE COPAY
$65 Copay
$65 Copay
$75 Copay
PREVENTIVE CARE
Covers 100%; Deductible waived
Covers 100%; Deductible waived
Covers 100%; Deductible waived
HOSPITAL SERVICES
Deductible then 100% Carrier
80% Carrier/20% Insured
80% Carrier/20% Insured
EMERGENCY TREATMENT ER
$400 Copay
$250 Copay + 20% Insured
$250 Copay + 20% Insured
Deductible waived; Copay waived if admitted Deductible waived; Copay waived if admitted
Deductible waived; Copay waived if admitted
PRESCRIPTION DRUGS
DEDUCTIBLE
None
None
None
RX (Formulary)
Tier 1
$3 A/$10 Copay
$3 A/$10 Copay
$3 A/$10 Copay
Tier 2
$30 Copay
$30 Copay
$30 Copay
Tier 3
$60 Copay
$60 Copay
$60 Copay
Mail Order Available Tier 4
or Specialty
$150 Form/$300 Non-Form
$150 Form/$300 Non-Form
$150 Form/$300 Non-Form
OUT-OF-NETWORK BENEFITS
CALENDAR YEAR DEDUCTIBLE
SINGLE
$5,000
$5,000
$6,000
FAMILY
$10,000
$10,000
$12,000
COINSURANCE (after deductible)
AETNA
70%
60%
60%
INSURED
30%
40%
40%
OUT-OF-POCKET (OOP):
Includes all Copays, deductibles & coinsurance
SINGLE
$10,000
$15,000
$16,000
FAMILY
$20,000
$30,000
$32,000
PHYSICIAN OFFICE VISIT
Deductible + 30% Coinsurance
Deductible + 40% Coinsurance
Deductible + 40% Coinsurance
HOSPITAL SERVICES
Deductible + 30% Coinsurance
Deductible + 40% Coinsurance
Deductible + 40% Coinsurance
EMERGENCY TREATMENT ER
Same As In-Network
Same As In-Network
Same As In-Network
PRESCRIPTION DRUGS
DEDUCTIBLE
None
None
None
RX (Formulary)
Tier 1/1A
$3 A/$10 Copay
$3 A/$10 Copay
$3 A/$10 Copay
Tier 2
$30 Copay
$30 Copay
$30 Copay
Tier 3
$60 Copay
$60 Copay
$60 Copay
Tier 4 or Specialty
N/A
N/A
N/A
See corresponding Summary of Benefits and Coverage for additional information regarding each plan.