Page 7 - C.J. Segerstrom 2022 Benefit Guide

MEDICAL PLANS (continued)

Aetna PPO $750 OAMC Aetna CDHP

Plan Provisions In-Network Out-of-Network In-Network Out-of-Network
$2,000 Single $2,800 Single
Annual Deductible $2,800 Individual $2,800 Individual
(Single/Family) $750/$1,500 $1,500/$3,000 within a Family within a Family
$4,000 Family $5,600 Family
Out-of-Pocket Maximum
(Includes Deductible) $3,000/$6,000 $6,000/$12,000 $4,000/$8,000 $8,000/$16,000
Lifetime Maximum Unlimited Unlimited
Preventive Care No Charge 40%* No Charge 40%*

Primary Physician Office Visit $20 copay 40%* 20%* 40%*
Specialist Office Visit $25 copay 40%* 20%* 40%*
Most X-Ray and Lab Services 20%* 40%* 20%* 40%*

Inpatient Hospital Services 20%* 40%* 20%* 40%*
Outpatient Hospital Services 20%* 40%* 20%* 40%*
Urgent Care $35 copay 40%* 20%* 40%*
Emergency Room Care 20% after $250 copay (deductible waived) 20%*
$25 copay/$20 copay
Chiropractic Care/Acupuncture 40%*; 20 visits max 20%*; 20 visits max 40%*; 20 visits max
(20 visits max)
Prescription Drug Deductible
(Individual/Family) None Medical Plan Deductible Applies
Retail Prescription Drugs (30-day supply)
Generic $10 copay Not Covered $10 copay Not covered
Brand Preferred $30 copay Not Covered $30 copay Not covered
Brand Non-Preferred $50 copay Not Covered $50 copay Not covered
Mail Order Prescription Drugs (90-day supply)
Generic $20 copay Not Covered $20 copay Not Covered
Brand Preferred $60 copay Not Covered $60 copay Not Covered
Brand Non-Preferred $100 copay Not Covered $100 copay Not Covered
Bi-weekly Cost (non-tobacco)**
Employee Only $103.75 $75.68
Employee + Spouse $278.79 $226.79
Employee + Child(ren) $233.40 $177.75
Employee + Family $471.09 $405.38
*After deductible is met
**If you use tobacco, you will be charged an additional $50 per month.
Note: This is a summary only of your coverage. In-network services are based on negotiated charges; out-of-network services are based on

How to Find an Aetna PPO/HSA Provider:

1. Go to http://www.aetna.com/docfind/home.do
2. Continue as Guests

3. Select Plan From an Employer
4. Enter your zip code and click Search
5. Under Select a Plan look for Aetna Open Access Plan and circle Managed Choice POS (Open Access)
6. Under Category select first left box “Medical Doctors & Specialists”
7. Click on Doctors (Primary Care) box
8. Select your choice of Primary care physician

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