Page 7 - Future Steps
P. 7
Medical/Prescription Drug Benefit Summary 2017 Beneits Enrollment
Aetna Aetna
High Deductible Plan Traditional Plan
In-Network Out-of-Network In-Network Out-of-Network
F+W Contribution to HSA Employee (Ee) only coverage: $250 N/A
Ee + spouse or Ee + child(ren): $500
Family: $750
Calendar Year Deductible Non-Embedded Embedded
Individual $2,000 $5,000 $1,000 $3,000
Family $4,000 $10,000 $2,000 $6,000
Out-of-Pocket Maximum—Includes Deductibles and Copays
Individual $5,800 $15,000 $3,000 $6,000
Family $7,150 $30,000 $6,000 $12,000
Covered Services (Member Responsibility Shown)
Primary Care Physician Office 20% after deductible 50% after deductible $35 copay 40% after deductible
Visit
Specialist Office Visit 20% after deductible 50% after deductible $50 copay 40% after deductible
Preventive Care Covered at 100% 50% after deductible Covered at 100% 40% after deductible
Urgent Care 20% after deductible 50% after deductible $75 copay 40% after deductible
Emergency Room 20% after deductible 20% after deductible $200 copay $200 copay
Inpatient Hospital Services 20% after deductible 50% after deductible 20% after deductible 40% after deductible
and $250 copay and $250 copay
Outpatient Hospital Services 20% after deductible 50% after deductible 20% after deductible 40% after deductible
Prescription Drugs
Deductible Medical deductible must None
be met before copays
apply
Retail—30 day supply
Generic $20 copay Not covered $10 copay Not covered
Brand Formulary $40 copay $30 copay
Brand Non-Formulary $70 copay 50%
Mail Order—31–90 day supply
Generic $40 copay N/A $20 copay N/A
Brand Formulary $80 copay $60 copay
Brand Non-Formulary $140 copay $125 copay
USPSTF preventive
drugs covered at 100%
Note
1. This is a synopsis of coverage only; the beneits summary contains exclusions and limitations which are not shown
here. Please refer to the beneits summary for the full scope of coverage.
2. In-network services are based on negotiated charges; out-of-network services are based on Reasonable and
Customary (R&C) charges.
7
Aetna Aetna
High Deductible Plan Traditional Plan
In-Network Out-of-Network In-Network Out-of-Network
F+W Contribution to HSA Employee (Ee) only coverage: $250 N/A
Ee + spouse or Ee + child(ren): $500
Family: $750
Calendar Year Deductible Non-Embedded Embedded
Individual $2,000 $5,000 $1,000 $3,000
Family $4,000 $10,000 $2,000 $6,000
Out-of-Pocket Maximum—Includes Deductibles and Copays
Individual $5,800 $15,000 $3,000 $6,000
Family $7,150 $30,000 $6,000 $12,000
Covered Services (Member Responsibility Shown)
Primary Care Physician Office 20% after deductible 50% after deductible $35 copay 40% after deductible
Visit
Specialist Office Visit 20% after deductible 50% after deductible $50 copay 40% after deductible
Preventive Care Covered at 100% 50% after deductible Covered at 100% 40% after deductible
Urgent Care 20% after deductible 50% after deductible $75 copay 40% after deductible
Emergency Room 20% after deductible 20% after deductible $200 copay $200 copay
Inpatient Hospital Services 20% after deductible 50% after deductible 20% after deductible 40% after deductible
and $250 copay and $250 copay
Outpatient Hospital Services 20% after deductible 50% after deductible 20% after deductible 40% after deductible
Prescription Drugs
Deductible Medical deductible must None
be met before copays
apply
Retail—30 day supply
Generic $20 copay Not covered $10 copay Not covered
Brand Formulary $40 copay $30 copay
Brand Non-Formulary $70 copay 50%
Mail Order—31–90 day supply
Generic $40 copay N/A $20 copay N/A
Brand Formulary $80 copay $60 copay
Brand Non-Formulary $140 copay $125 copay
USPSTF preventive
drugs covered at 100%
Note
1. This is a synopsis of coverage only; the beneits summary contains exclusions and limitations which are not shown
here. Please refer to the beneits summary for the full scope of coverage.
2. In-network services are based on negotiated charges; out-of-network services are based on Reasonable and
Customary (R&C) charges.
7
