Page 5 - 2022 Arabella Advisors Benefit Guide

Medical Coverage – Benefits

Each plan uses the Aetna Choice® POS II (Open Access) network

PPO Medical HRA Plan PPO Medical HSA Plan
Plan Provisions

In- Out-of- In- Out-of-
Network Network Network Network

Annual Deductible $1,800 / $3,600 / $3,000 / $6,000 /
(Individual/Family) $3,600 $7,200 $6,000 $12,000

Annual Employer
contributions $375 / $750 $600 / $1,200
(Individual/Family)

Out-of-Pocket Maximum $4,500 / $6,500 / $5,000 / $10,000 /
(Includes Deductible)
(Individual/Family) $9,000 $13,000 $10,000 $20,000

Lifetime Maximum Unlimited Unlimited

80% after 80% after
Preventive Care 100% 100%
deductible deductible

$25 copay for
Physician / Specialist Office Primary 80% after 95% after 80% after
Visit $50 copay for deductible Deductible deductible
Specialist

Urgent Care $75 copay 95% after Deductible

80% after 95% after 80% after
X-Ray and Lab $25 copay
deductible deductible deductible

95% after deductible 80% after 95% after 80% after
Inpatient Hospital Services
and $300 copay deductible deductible deductible

80% after 95% after 80% after
Outpatient Hospital Services 95% after deductible
deductible deductible deductible

Emergency Room Care $200 per visit
95% after deductible
Ambulance Services $75 copay

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