Page 4 - Citizens Bank 2021 Benefit Guide

Medical Plan Option:

The Protect Plans - administered by Meritain

Aetna Choice POS II Network

Per Pay Period
Dependent Information
Employee Only $ 40.00
Citizens Bank of Ada offers employees the
Employee + Spouse $ 269.09 opportunity to cover their spouse and
dependent children. Children can join or
Employee + Child(ren) $ 222.43 remain on a parent’s medical plan until

Employee + Family $ 362.40 age 26.

Members Cost
In-Network Out-of-Network
Benefit Overview
Annual Calendar Deductible (CYD) Individual: $1,000 Individual: $3,000
January 1 to December 31 Family: $2,000 Family: $6,000
Member: 20% Member: 40%
Co-Insurance
Insurance Carrier: 80% Insurance Carrier: 60%

Annual Out of Pocket Maximum Individual: $3,000 Individual: $5,000
(Includes, CYD, Co-Pays, Co-Insurance) Family: $6,000 Family: $10,000

Maximum Benefit (some limits apply) Unlimited
Physician Services: (Dr. Services Only)
Primary Office Visit $25 Copay 40% After Annual Deductible
Specialist Office Visit $50 Copay 40% After Annual Deductible
Telemedicine (Teladoc) 24/7 $10 Copay Not Covered
Chiropractic Office Visit (Limits Apply) $25 Copay 40% After Annual Deductible
Acupressure Office Visit (Limits Apply) $25 Copay 40% After Annual Deductible

Preventive Care Covered 100% Not Covered

Labs / X-rays / Tests:
Lab / X-ray (Diagnostic) 20% After Annual Deductible 40% After Annual Deductible
Lab (Preventive) Covered 100% 40% After Annual Deductible
X-ray (Preventive) Covered 100% 40% After Annual Deductible
CT, PET, MRI, MRA (Major) 20% After Annual Deductible 40% After Annual Deductible

Urgent Care $150 Copay 40% After Annual Deductible
20% After CYD (Emergency
Emergency Room 20% After Annual Deductible
40% After CYD (Non-Emergency

Pharmacy Retail 30 Days: Network Pharmacies Non-Network Pharmacies
Pharmacy Deductible NONE Not Covered
Generic $10 Copay / $20 Copay Mail Order Not Covered
Name Brand (Preferred) $35 Copay / $70 Copay Mail Order Not Covered
Name Brand (Non-Preferred) 50% Copay Retail & Mail Order Not Covered
Specialty Drugs (30 Days) 35% Copay up to $300 Max Not Covered

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
4 Website: www.myMERITAIN.com or Customer Service: 1-888-306-9215