Page 7 - Leona Arizona Employment Group Flipbook
P. 7

Medical and Pharmacy Coverage




          For more information about your HRA, please see page 10.

                                                                 CHDP/HRA Plan ($2,000 Deductible)
           Medical Plan Provisions                       In-Network                         Out-of-Network
           Annual Deductible (Individual/Family)        $2,000/$4,000                       $4,000/$8,000
                            1
           Member Coinsurance                               20%                                 50%
           Out-of-Pocket Maximum                        $4,000/$8,000                      $12,000/$24,000
           (Includes Deductible)
           Preventive Care                             Covered at 100%                       Not covered
           Primary Care Provider Office Visit               20%*                                50%*
           Specialist Office Visit                          20%*                                50%*
           X-Ray, Lab and Complex Imaging                   20%*                                50%*
           Inpatient Hospital Services                      20%*                                50%*
           Outpatient Hospital Services
           & Freestanding Facilities                        20%*                                50%*
           Urgent Care                                      20%*                                50%*
           Emergency Room                                   20%*                                20%*
           Spinal Manipulation Therapy                      20%*                                50%*
           (Limited to 30 visits per year)
           Acupuncture (Limited to 10 visits per year)      20%*                                50%*
           Pharmacy Provisions
           Pharmacy Plan Type                                      Aetna Standard Open Formulary
           Retail Pharmacy
                         2
           Generic                                        $15 copay                          Not covered
           Brand Preferred                                $40 copay                          Not covered
           Brand Non-Preferred                            $70 copay                          Not covered
                             3
           Mail Order Pharmacy
           Generic                                       $37.50 copay                        Not applicable
           Brand Preferred                               $100 copay                          Not applicable
           Brand Non-Preferred                           $175 copay                          Not applicable
          * After deductible
          1  Applies to all expenses unless otherwise stated
          2  Retail Pharmacy coverage is up to a 30-day supply from Aetna National Network. A 31 to 90-day supply is covered at retail pharmacies in the Extended Day
          Supply Network.
          3  Mail Order Pharmacy coverage is from a 31 to 90-day supply offered by CVS Caremark® Mail Service Pharmacy.

             Important Notes

              Specialty Drug coverage is up to a 30-day supply. All prescription fills must be through our preferred specialty pharmacy
               network. Refer to Aetna’s Specialty Performance Network Drug List.
              This is a synopsis of coverage only; the benefits summary contains exclusions and limitations that are not shown here.
               Please refer to the benefits summary for the full scope of coverage.
              In-Network services are based on negotiated charges; Out-of-Network services are based on Reasonable & Customary
               (R&C) charges.



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