Page 4 - 2025 US Neuro LLC - Benefit Guide-R4

Medical Option:

Meritain Health (Aetna POS II)

2025 H.S.A Bronze Silver Gold
Effective 7-1-25 Plan Plan Plan Plan We offer our full-time employees and
Bi-Weekly (26) Per Pay Period their eligible dependents coverage.
Employee Only $ 72.56 $ 60.81 $ 75.93 $ 86.95 Children can join or remain on a parent’s
medical plan until age 26. When a child
Employee + Spouse $193.57 $170.08 $200.32 $222.36
turns 26, they will lose medical coverage
Employee + Child(ren) $160.55 $141.64 $165.98 $183.72 on the last day of their birth month.
Employee + Family $303.27 $269.32 $313.02 $344.87
H.S.A Plan Bronze Plan Silver Plan Gold Plan
Brief Member
In-Network Summary $5,000 Deductible $5,000 Deductible $3,000 Deductible $2,000 Deductible
IN & OUT of NEWORK IN and OUT of NETWORK IN and OUT of NEWORK IN and OUT of NEWORK

Difference Between HSA-Compatible High Deductible Lower cost option with FIRST Dollar cover- Mid COST option with FIRST Dollar cover- Higher cost option with FIRST Dollar cover-
age with Copays (CYD Waived) on MOST age with Copays (CYD Waived) on MOST
age with Copays (CYD Waived) on MOST
Plans Health Plans (HDHP) Day to Day Services Higher CYD / OOP Day to Day Services. Mid-range CYD / OOP Day to Day Services. Lower CYD / OOP
Network Aetna Choice POS II Aetna Choice POS II Aetna Choice POS II Aetna Choice POS II
(CYD) Calendar Year Individual: $5,000 Individual: $5,000 Individual: $3,000 Individual: $2,000
Deductible (Jan .1st to Dec. 31st) Family: $10,000 Family: $10,000 Family: $6,000 Family: $4,000
Coinsurance Carrier: 100% Carrier: 80% Carrier: 80% Carrier: 80%
(After CYD) Member: 0% Member: 20% Member: 20% Member: 20%
Annual (OOP) Out of Individual: $5,000 Individual: $8,150 Individual: $6,000 Individual: $5,000
Pocket Maximum Family: $10,000 Family: $16,300 Family: $12,000 Family: $10,000
(PCP) Primary Care 0% after CYD $30 Copay $30 Copay $25 Copay
Physician
Specialist Physicians 0% after CYD $60 Copay $60 Copay $50Copay
and Providers
Dr. Consultation
0% after CYD $30 PCP/ $60 Specialist $30 PCP/ $60 Specialist $30 PCP/ $60 Specialist
Telemedicine Visits
Teladoc Virtual Visits Member Pays $56 Cost
(see page 6) Per Consultation $0 Copay $0 Copay $0 Copay
Basic: Lab, X-Rays & Basic: Covered 100%
Diagnostic Basic: Covered 100% CYD Waived Basic: Covered 100% Basic: Covered 100%
Major: Diagnostic & CYD Waived Major: $200 Copay/$100(USIN) CYD Waived CYD Waived
Imaging *US Imaging Major: 0% after CYD See Page 8 For Info Major: $200 Copay/$100(USIN) Major: $200 Copay/$100(USIN)
Network® (USIN) See Page 8 For Info See Page 8 For Info
(See Page 8 for details)
Annual Preventive
Covered 100% Covered 100% Covered 100% Covered 100%
Care Certain Rx are (No CYD, Coins. Copay) (No CYD, Coins. Copay) (No CYD, Coins. Copay) (No CYD, Coins. Copay)
covered too. (Page 5)
Minute Clinic Visits 0% after CYD $0 Copay $0 Copay $0 Copay
(see page 7)
Urgent Care 0% after CYD $75 Copay (CYD Waived) $75 Copay (CYD Waived) $75 Copay (CYD Waived)
$300 Copay + 20% Coins $300 Copay + 20% Coins $300 Copay + 20% Coins
Emergency Room 0% after CYD
(NO CYD) (NO CYD) (NO CYD)
Hospitalization: 0% after CYD 20% after CYD 20% after CYD 20% after CYD
In / Outpatient

Prescription Drugs - 31
T
e
T
i
Tier 1 $0 Copay r 1 $0 Copay r 1 $0 Copay
e
i
Day Supply Retail
e
e
i
T
0% after CYD Tier 2 $10 Copay r 2 $10 Copay r 2 $10 Copay
T
i
90 Day Supply Mail
Tier 3 $50 Copay Tier 3 $50 Copay Tier 3 $50 Copay
Order 2.5 Times Retail
Tier 4 $100 Copay Tier 4 $100 Copay Tier 4 $100 Copay
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