Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Aetna Open Access Managed Choice POS PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$750/$1,500
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20
Specialist Visit
$40
Urgent Care
$50
Emergency Room
20% after $250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$30
Non-Preferred Brand
$50
Specialty
$250
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$60
Non-Preferred Brand
$100
Specialty
Not covered
* After deductible
Out-of-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
40%*
Primary Care Visit
40%*
Specialist Visit
40%*
Urgent Care
40%*
Emergency Room
20% after $250 copay
Retail Rx (Up to 30-Day Supply)
Generic
20% up to $250 maximum
Preferred Brand
20% up to $250 maximum
Non-Preferred Brand
20% up to $250 maximum
Specialty
20%
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Aetna Open Access Managed Choice PPO HDHP
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,500/$7,000
Out-of-Pocket Max (Individual/Family)
$6,550/$13,100
Preventive Care
$0
Primary Care Visit
10%*
Specialist Visit
10%*
Urgent Care
10%*
Emergency Room
10%*
Retail Rx (Up to 30-Day Supply)
Generic
$10*
Preferred Brand
$30*
Non-Preferred Brand
$50*
Specialty
$250*
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20*
Preferred Brand
$60*
Non-Preferred Brand
$100*
Specialty
Not covered
* After deductible
Out-of-Network
Deductible (Individual/Family)
$10,000/$20,000
Out-of-Pocket Max (Individual/Family)
$13,100/$26,200
Preventive Care
30%*
Primary Care Visit
30%*
Specialist Visit
30%*
Urgent Care
30%*
Emergency Room
10%*
Retail Rx (Up to 30-Day Supply)
Generic
20%* up to $250 maximum
Preferred Brand
20%* up to $250 maximum
Non-Preferred Brand
20%* up to $250 maximum
Specialty
20%*
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Aetna Value (AVN) HMO (CA Only)
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20
Specialist Visit
$40
Urgent Care
$50
Emergency Room
$150*
Retail Rx (Up to 30-Day Supply)
Generic
$10*
Preferred Brand
$30*
Non-Preferred Brand
$50*
Specialty
20%* up to $100 maximum
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20*
Preferred Brand
$60*
Non-Preferred Brand
$100*
Specialty
Not covered
* After deductible
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Aetna Full HMO (CA Only)
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
None/None
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$30
Specialist Visit
$45
Urgent Care
$50
Emergency Room
$100
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$30
Non-Preferred Brand
$50
Specialty
20% up to $100 maximum
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$60
Non-Preferred Brand
$100
Specialty
Not covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX