Page 139 - outbind://23/
P. 139
Aetna
HMO 20 HMO 30
Value Network Value Network
GOLD GOLD
(prev: SELECT 30) (prev: SELECT 40)
Annual Deductible None None
$20 ‐ Primary $30 ‐ Primary
Office Visit
$60 ‐ Specialist $60 ‐ Specialist
$4,500 ‐ Individual $5,000 ‐ Individual
Out‐Of‐Pocket Max.
$9,000 ‐ Family $10,000 ‐ Family
RX (Pharmacy Drug) 1,2,3,4 $20/$50/$50/30% $20/$50/$50/30%
$250 deductible on $250 deductible on
Separate Deductible may apply other than tier 1 ‐ other than tier 1 ‐
Genetic Genetic
Inpatient Hospital Charges $750/admit $500/day‐3 days
Outpatient Medical Services $600 $600
Test ‐ Lab / X‐Ray / Imaging $20 / $60 / $250 $30 / $60 / $250
