Page 10 - IPsoft 2018 Benefits Guide
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BRIEF SUMMARY OF AETNA MEDICAL PLAN BENEFITS
BENEFIT HIGHLIGHTS
Deductible
Out-of-Pocket Maximum
Primary Care Of ce Visit Copay
Complex Imaging
Diagnostic X-Ray/Labs
Emergency Room
Pharmacy Copays (Retail Store)
OAMC EPO
N/A
$5,080 Individual / $12,700 Family
$25 copay
$75 copay
Covered 100%
$125 per visit copay (waived if admitted), then plan pays 100%
$5 Generic (Tier 1)
$35 Brand (Tier 2)
$70 Non-preferred Brand (Tier 3)
(In-Network Coverage Only)
Coinsurance
None
Adult Preventative Care
No Charge
Specialty Care Of ce Visit Copay
$25 copay
Hospital Outpatient
Covered 100%
Hospital Inpatient
10% after deductible
Lifetime Maximum
Unlimited
Pharmacy Copays Mail Order
$10 / $70 / $120
Please refer to full Summary of Bene ts enclosure for fee schedule for more services.
2018 Benefits
