Page 4 - 2019 Benefits Enrollment

MEDICAL

Choosing the right health plan is probably one of the most important decisions you can make for yourself and your family
members. Please carefully consider the plan information provided in this document.

Busey ofers two plans through Aetna: the 2700 CDHP and the 5000 CDHP. We understand paying the plan deductible up front
under a CDHP may be overwhelming. To help associates with this cost, Busey is providing two items which will be discussed
later in this guide: HSA seed money through B Well and a concierge vendor—Compass. Visit www.aetna.com .

POS 2700 CDHP POS 5000 CDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,700 $10,000 $5,000 $10,000
Family $5,400 $20,000 $10,000 $20,000
Out-of-Pocket Maximum
Individual $5,000 $15,000 $5,000 $15,000
Family $10,000 $30,000 $10,000 $30,000
Physician Oice Visits
Primary care 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Specialist 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Wellness/Preventive
$0 50% coinsurance $0 50% coinsurance
Urgent Care
20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Lab Services/X-Ray
Physician oice 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient facility 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient hospital 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Hospital Services
Inpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Emergency room 20% coinsurance 20% coinsurance 0% coinsurance 0% coinsurance
Mental Health/Substance Abuse
Inpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Oice visits 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Chiropractic Care
20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Prescription Drugs
Retail supply limit 30 days 30 days 30 days 30 days
„ Tier 1 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
„ Tier 2 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
„ Tier 3 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Mail order supply limit 90 days 90 days
„ Tier 1 20% coinsurance 0% coinsurance
„ Tier 2 20% coinsurance 0% coinsurance
„ Tier 3 20% coinsurance 0% coinsurance

4 2019 Benefits Enrollment