Page 5 - The Gori Law Firm 2020-21 Benefits Guide

2020-2021
Enrollment Guide

Medical Plan Details

Aetna
In-Network Out-of-Network
Calendar Year Deductible
Individual $3,000 $6,000
Family $6,000 $12,000
Annual Out-of-Pocket Maximum (includes deductible)
Individual $7,150 $14,500
Family $14,300 $29,000
Physician Oice Visits
Preventive Care Covered at 100% 30% after deductible
Telemedicine** $25 copay 30% after deductible
Walk-In Clinic $25 copay 30% after deductible
Primary Care Visit $25 copay 30% after deductible
Specialist Visit $75 copay 30% after deductible
Urgent Care* $75 copay 30% after deductible
Hospital Services
Inpatient 100% after deductible 30% after deductible
Outpatient 100% after deductible 30% after deductible
Emergency Room* $300 copay $300 copay
Prescription Drugs—30-day supply
Value $3 copay 20% after copay
Preferred Generic $10 copay 20% after copay
Non-Preferred Generic $60 copay 20% after copay
Preferred Brand $35 copay 20% after copay
Non-Preferred Brand $60 copay 20% after copay
Preferred Specialty $150 copay 20% after copay
Non-Preferred Specialty $300 copay 20% after copay
Retail/Mail Order—31-90-day supply
Value $7.50 copay 20% after copay
Preferred Generic $25 copay 20% after copay
Non-Preferred Generic $150 copay 20% after copay
Preferred Brand $87.50 copay 20% after copay
Non-Preferred Brand $150 copay 20% after copay
* Urgent Care and Emergency Room coverage is 50% after the deductible for non-emergency use

** Telemedicine visits with a specialist will be a $75 copay

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