Page 6 - 2016 New Hire Guide (Non-PA)

New Hire Guide

Medical Coverage

Plan 1 Plan 2 Plan 3
Aetna Aetna Choice POS II Aetna Choice POS II
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Individual deductible $250 $1,000 $350 $1,400 $500 $1,500
Family deductible $500 $2,000 $700 $2,800 $1,500 $4,500
Compliant 100% 50% 90% 50% 80% 50%
coinsurance
Compliant individual $1,250 $2,500 $2,000 $4,000 $2,750 $4,500
out-of-pocket
maximum
Compliant family out- $2,500 $5,000 $4,000 $8,000 $8,250 $13,500
of-pocket maximum
Preventive care 100% no deductible 100% no deductible 100% no deductible
Primary care visits $20 copay 50% after $20 copay 50% after $20 copay 50% after
deductible deductible deductible
Specialist visits $40 copay 50% after $40 copay 50% after $40 copay 50% after
deductible deductible deductible
Inpatient services 100% after 50% after 90% after 50% after 80% after 50% after
deductible deductible deductible deductible deductible deductible
Outpatient services 100% after 50% after 90% after 50% after 80% after 50% after
deductible deductible deductible deductible deductible deductible
Emergency room $75 copay $75 copay $75 copay $75 copay $75 copay $75 copay
Urgent care $40 copay 50% after $40 copay 50% after $40 copay 50% after
deductible deductible deductible

Pharmacy Coverage
Plan 1 Plan 2 Plan 3
Aetna Aetna Choice POS II Aetna Choice POS II
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Retail supply limit 31 days 31 days 31 days
Deductible—separate Individual $100 Individual $100 Individual $100
from medical Family $200 Family $200 Family $200
Out-of-pocket Individual $1,000 Individual $1,000 Individual $1,000
maximum—separate Family $2,000 Family $2,000 Family $2,000
from medical
Tier 1 80% after deductible 80% after deductible 80% after deductible
Tier 2 60% after deductible 60% after deductible 60% after deductible
Tier 3 40% after deductible 40% after deductible 40% after deductible
Specialty 20% ($40 min/$80 max) 20% ($40 min/$80 max) 20% ($40 min/$80 max)
Mail order supply 90 days 90 days 90 days
limit
Tier 1 80% after deductible 80% after deductible 80% after deductible
Tier 2 60% after deductible 60% after deductible 60% after deductible
Tier 3 40% after deductible 40% after deductible 40% after deductible
Specialty Limited to a Not covered Limited to a Not covered Limited to a Not covered
31-day ill 31-day ill 31-day ill

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