Page 7 - PageGroup | 2022 Benefits Guide | Temp Employees
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BRIEF SUMMARY OF AETNA MEDICAL PLAN BENEFITS
BENEFIT HIGHLIGHTS
Employer Paid HRA Funding Deductible Coinsurance Out-of-Pocket Maximum Adult Preventative Care Primary Care Office Visit Copay Specialty Care Office Visit Copay Complex Imaging Hospital Outpatient Diagnostic X-Ray/Labs Hospital Inpatient Emergency Room Lifetime Maximum
Pharmacy Copays (Retail Store) Pharmacy Copays Mail Order
In-Network Coverage
OAMC POS
N/A
Out-of-Network Coverage
$1,000 Individual / $2,000 Family
$1,250 Individual / $2,500 Family
$25 copay
No Charge, deductible waived
No Charge, deductible waived
$2,000 Individual / $4,000 Family
$3,000 Individual / $6,000 Family
30% after deductible
30% after deductible
30% after deductible
10% of contracted rate after deductible
30% after deductible
No Charge
30% after deductible
$40 copay
30% after deductible
10% of contracted rate after deductible
30% after deductible
10% of contracted rate after deductible
30% after deductible
$200 per visit copay (waived if admitted), then plan pays 100%
Unlimited
Unlimited
$5 Generic (Tier 1)
$20 Brand (Tier 2)
$40 Non-preferred Brand (Tier 3)
30% of submitted cost; after applicable copay
$10 / $40 / $80
N/A
Please refer to full Summary of Benefits enclosure for fee schedule for more services.
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