Page 7 - 2016 Enrollment

Medical/Prescription Drug Benefit Summary

Aetna Aetna
Network: Choice POS II High Deductible Plan Traditional Plan
In-Network Out-of-Network In-Network Out-of-Network
F+W contribution to Employee (Ee) only coverage: $250
HSA Ee + spouse or Ee + child(ren): $500 N/A
Family: $750
Calendar Year Deductible
Individual $2,000 $5,000 $750 $1,500
Family $4,000 $10,000 $1,500 $4,500
Out-of-Pocket Maximum—includes deductibles and copays
Individual $5,800 $15,000 $2,500 $5,500
Family $6,850 $30,000 $4,500 $10,500
Covered Services (member responsibility shown)
Primary care physician 20% after deductible 50% after deductible $35 copay 40% after deductible
ofice visit
Specialist ofice visit 20% after deductible 50% after deductible $45 copay 40% after deductible
Preventive care Covered at 100% 50% after deductible Covered at 100% 40% after deductible
Urgent care 20% after deductible 50% after deductible $75 copay 40% after deductible
Emergency room 20% after deductible 20% after deductible $150 copay $150 copay
Inpatient hospital 20% after deductible 50% after deductible 20% after deductible 40% after deductible
services and $250 copay and $250 copay
Outpatient hospital 20% after deductible 50% after deductible 20% after deductible 40% after deductible
services
Prescription Drugs
Medical deductible must
Deductible be met before copays None
apply
Retail—30 day supply
Generic $20 copay $10 copay
Brand formulary $40 copay Not covered $30 copay Not covered
Brand non-formulary $70 copay 50%
Mail Order—31–90 day supply
Generic $40 copay $20 copay
Brand formulary $80 copay N/A $60 copay N/A
Brand non-formulary $140 copay $125 copay
USPSTF preventive
drugs covered at 100%
Note
1. This is a synopsis of coverage only; the beneits summary contains exclusions and limitations that are not shown
here. Please refer to the beneits summary for the full scope of coverage.
2. In-network services are based on negotiated charges; out-of-network services are based on Reasonable and
Customary (R&C) charges.

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