Page 6 - Zelis 2022 Executive Benefits Guide

Medical Benefits
Administered by Ameriben
Visit www.ameriben.com to locate Aetna participating providers in your area.
Deductible
(Individual/Family)
Coinsurance
Out of Pocket Max
(Individual/Family)
Preventive Care
Office Visit
Primary Care
Specialist
Independent Diagnostic Labs
Blood Work
X-ray
Advanced Imaging Services
Inpatient Hospital Facility Fee
Outpatient Hospital Facility Fee
Ambulatory Surgical Fee
Urgent Care
Emergency Room
PPO 1500
$1,500/$3,000
20%
$4,500/$9,000
$30 Copayment
$50 Copayment
20% after deductible
20% after deductible
20% after deductible
20% after deductible
20% after deductible
20% after deductible
$50 Copayment
$150 Copayment
HSA 2800
$2,800/$5,600
0%
$2,800/$5,600
Covered 100% (In-Network only)
HSA 5000
$5,000/$10,000
0%
$5,000/$10,000
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
100% after deductible
Deductible
$0
$2,800/$5,600
$5,000/$10,000
Generic
$15
100% after deductible
Preferred Brand
$40
100% after deductible
Non-Preferred Brand
$60
100% after deductible
Deductible
(Individual/Family)
$4,000/$8,000
$5,000/$10,000
$10,000/$20,000
Coinsurance
30%
30%
30%
Out of Pocket Max
(Individual/Family)
$8,000/$16,000
$10,000/$20,000
$20,000/$40,000
Associate Only
$88.32
$69.68
$60.32
Associate + Spouse
$244.80
$162.24
$133.12
Associate + Child(ren)
$192.00
$130.00
$109.20
Associate + Family
$348.96
$199.68
$180.96
6
2022 Benefits Guide
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. For more details about your medical plan please refer to the appropriate summary plan description (SPD).
Contributions Per Pay Period
Out-of Network Prescriptions In-Network