Page 7 - LADACIN 2022-23 Benefit Guide

Medical Plan Comparison

Here’s how the medical plans compare. The costs below represent what you pay for each service.

Aetna EPO Aetna HDHP

In-Network Out-of-Network In-Network Out-of-Network
Plan Provision

Annual Deductible (Individual/Family) $0/$0 N/A $1,500/$3,000 $1,500/$3,000
Out-of-Pocket Maximum (Includes $3,500/ $5,000/ $10,000/
N/A
Deductible) $7,000 $10,000 $20,000
Unlimited
Lifetime Maximum Unlimited

Preventive Care Covered at 100% Covered at 100% Covered at 100%

Primary Physician Office Visit $15 No Charge after ded 30% after ded

Specialist Office Visit $25 No Charge after ded 30% after ded

$0
X-Ray and Lab Not Covered No Charge after ded 30% after ded
(Quest/ Lab Corp) Complex Imaging
$25 copay
$500 Copay/Day to
Inpatient Hospital Services No Charge after ded 30% after ded
5 days
Freestanding
Outpatient Hospital Services No Charge after ded 30% after ded
$200 copay
Urgent Care $25 Copay No Charge after ded 30% after ded

Emergency Room Care $100 Copay No Charge after ded

Prescription Drug Deductible $0 Integrated with Medical
(Individual/Family)
Retail Prescription Drugs
(30-day supply)
• Generic $20 $20
• Brand Preferred $40 $40
• Brand Non-preferred $70 $70
Mail Order Prescription Drugs
(90-day supply)
• Generic $40 $40
• Brand Preferred $80 $80
• Brand Non-preferred $140 $140

Note: This is a summary of your coverage only. Please refer to your summary plan description for the full scope of coverage. In-network

services are based on negotiated charges; out-of-network services are based on reasonable and customary (R&C) charges.

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