Page 13 - OpenX 2022 Book of Benefits

PCP at time of sign-up, one will be referred to you within 30 days of the plan effective date. All
services are conveniently coordinated by your primary care physician, and covered services are
in-network only, ensuring you pay a lower rate by staying within the network. Specialist visits are
conveniently coordinated by your PCP via referral. Generally, an HMO operates as follows:

» With the exception of an OB/GYN specialist who is affiliated with your selected medical group,
you must receive a referral from your PCP before receiving services from a specialist.

» You and any enrolled dependent(s) are not required to see the same PCP, and you may
change your PCP at any time.

» Services may require a fixed-dollar payment up-front, called a co-payment.

» You do not have to submit claim forms to your insurance company.
» Any services rendered out-of-network without the proper referral from your PCP will not
be covered.

» If you elect to contribute to a flexible spending account, you can use your pre-tax funds to
pay for out-of-pocket medical costs.

The PPO

With a Preferred Provider Organization (PPO) plan you have greater flexibility and choice to use
both in-network and out-of-network physicians. However, you are encouraged to receive services
from Aetna in-network doctors, specialists and facilities to get a higher level of benefit.

Typically, the PPO plan requires a slightly higher monthly premium in exchange for the guarantee
that every time you see your doctor or specialist, you will pay the same rate. This plan’s highlights
include fixed-rate co-pays for office, specialist, telemedicine and some therapy visits; it does have
a small deductible or out-of-pocket cost, before coinsurance kicks in, for other covered services
such as lab work and X-rays. Also, you and any enrolled dependent(s) are permitted to visit any
doctor or facility without a referral from a Primary Care Physician (PCP).

» You and any enrolled dependent(s) are permitted to visit any doctor or facility without a
referral from a Primary Care Physician (PCP).

» Certain services, such as doctors’ visits, may require a fixed-dollar payment up front, referred
to as a copayment.

» Before the insurance company will pay certain medical expenses, you may be required to pay
a plan specific amount, referred to as the deductible.

» Once the deductible has been fulfilled, the insurance company will pay a large percentage
of the cost of your care, known as coinsurance. You are then financially responsible for the
remaining cost up to the out-of-pocket maximum.

» Claim forms are submitted to the insurance company on your behalf when services are
received from within the network.

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