Page 5 - Polyventive 2022 Benefits Guide
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2022 Benefits Guide
Medical and Prescription Drug Plans
Medical and Prescription coverage will be provided by Aetna. The program provides eligible Employees
access to a national network of healthcare providers who meet stringent credentialing standards. You will not
need a referral from your primary doctor to see a specialist in the network.
Side-by-Side Comparison of the Plan Options
Beneit Description $2,500 Ded PPO Option $3,000 Ded HSA Plan
Annual Deductible Network Non-Network Network Non-Network
Individual $2,500 $7,500 $3,000 $10,000
Family $7,500 $22,500 $6,000 $20,000
Out-of-Pocket Maximum (includes deductible and medical copays)
Individual $7,500 $22,500 $6,900 $20,000
Family $15,000 $45,000 $13,800 $40,000
Preventive Oice Visit Covered at 100% 70% AD Covered at 100% 70% AD
Primary Physician Oice Visit $30 copay 70% AD 80% AD 60% AD
Specialist Physician Oice Visit $60 copay 70% AD 80% AD 60% AD
Virtual Visits (Includes Behavioral Health and Covered at 100% Not covered 80% AD Not covered
Substance Abuse)
Urgent Care (Oice Setting/Walk-In Clinic) $60 copay 70% AD 80% AD 60% AD
$500 copay, then $500 copay, then
Emergency Care 80% AD 80% AD
80% (no ded) 80% (no ded)
Outpatient Lab and X-Ray in Dr’s Oice $30 copay 60% AD 80% AD 60% AD
Outpatient MRI/CT Scans/PET Scans/Nuclear Med 80% AD 60% AD 80% AD 60% AD
Outpatient Surgery (Hospital) 80% AD 60% AD 80% AD 60% AD
Inpatient Hospital Care 80% AD 60% AD 80% AD 60% AD
Ambulance (Emergency use) 80% AD 60% AD 80% AD 60% AD
Hospice 80% AD 60% AD 80% AD 60% AD
Skilled Nursing Facility (60 days combined net 80% AD 60% AD 80% AD 60% AD
and non-net)
Durable Medical Equipment 80% AD 60% AD 80% AD 60% AD
Lifetime Plan Maximum Unlimited Unlimited
This is a listing of the most commonly used beneits. For a complete listing of covered procedures, view the actual plan documents. Contact your HR
Department for a copy.
The Annual Deductible and Out-of-Pocket Maximums are calculated on a calendar year basis.
The Out-of-Pocket Maximum includes the Deductible.
Copayments, Coinsurance, and Deductibles accumulate towards the Out-of-Pocket Maximum.
Did you know? You can download the Aetna HealthSM app to get 24/7/365 access to your group health plan information, a
virtual ID card, ind care, check costs, see claims and get answers quickly. Available for Android or IOS.
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Medical and Prescription Drug Plans
Medical and Prescription coverage will be provided by Aetna. The program provides eligible Employees
access to a national network of healthcare providers who meet stringent credentialing standards. You will not
need a referral from your primary doctor to see a specialist in the network.
Side-by-Side Comparison of the Plan Options
Beneit Description $2,500 Ded PPO Option $3,000 Ded HSA Plan
Annual Deductible Network Non-Network Network Non-Network
Individual $2,500 $7,500 $3,000 $10,000
Family $7,500 $22,500 $6,000 $20,000
Out-of-Pocket Maximum (includes deductible and medical copays)
Individual $7,500 $22,500 $6,900 $20,000
Family $15,000 $45,000 $13,800 $40,000
Preventive Oice Visit Covered at 100% 70% AD Covered at 100% 70% AD
Primary Physician Oice Visit $30 copay 70% AD 80% AD 60% AD
Specialist Physician Oice Visit $60 copay 70% AD 80% AD 60% AD
Virtual Visits (Includes Behavioral Health and Covered at 100% Not covered 80% AD Not covered
Substance Abuse)
Urgent Care (Oice Setting/Walk-In Clinic) $60 copay 70% AD 80% AD 60% AD
$500 copay, then $500 copay, then
Emergency Care 80% AD 80% AD
80% (no ded) 80% (no ded)
Outpatient Lab and X-Ray in Dr’s Oice $30 copay 60% AD 80% AD 60% AD
Outpatient MRI/CT Scans/PET Scans/Nuclear Med 80% AD 60% AD 80% AD 60% AD
Outpatient Surgery (Hospital) 80% AD 60% AD 80% AD 60% AD
Inpatient Hospital Care 80% AD 60% AD 80% AD 60% AD
Ambulance (Emergency use) 80% AD 60% AD 80% AD 60% AD
Hospice 80% AD 60% AD 80% AD 60% AD
Skilled Nursing Facility (60 days combined net 80% AD 60% AD 80% AD 60% AD
and non-net)
Durable Medical Equipment 80% AD 60% AD 80% AD 60% AD
Lifetime Plan Maximum Unlimited Unlimited
This is a listing of the most commonly used beneits. For a complete listing of covered procedures, view the actual plan documents. Contact your HR
Department for a copy.
The Annual Deductible and Out-of-Pocket Maximums are calculated on a calendar year basis.
The Out-of-Pocket Maximum includes the Deductible.
Copayments, Coinsurance, and Deductibles accumulate towards the Out-of-Pocket Maximum.
Did you know? You can download the Aetna HealthSM app to get 24/7/365 access to your group health plan information, a
virtual ID card, ind care, check costs, see claims and get answers quickly. Available for Android or IOS.
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