Page 5 - NickCo Hospitality_2020 EE Benefits Guide_Mgmt

BENEFITS

Medical Insurance

Plan Name Aetna HMO Aetna OAMC PPO

Network Name Aetna Value Network (AVN) In-Network Non-Network
Health Benefits

Lifetime Maximum Benefit Unlimited Unlimited

Deductible (Annual)
- Individual $0 $1,000 $2,000
- Family $0 $2,000 $4,000

Co-Insurance (Plan Pays) 70% 80% 60%
Office Visit Copay
- Primary Care Physician $30 Copay $25 Copay Deductible, 40%
- Specialist Office Visit $40 Copay $50 Copay Deductible, 40%

Out-of-Pocket Maximum
- Individual $4,500 $3,500 $7,000
- Family $9,000 $7,000 $14,000

Hospitalization
- Inpatient 30% Deductible, 20% Deductible, 40%
- Outpatient 30% Deductible, 20% Deductible, 40%

Emergency Services $150 Copay $200 Copay + 20%

Ambulance Services (Emergency) $150 Copay Deductible, 20%

Urgent Care $50 Copay $50 Copay Deductible, 40%
Preventive Care No Charge No Charge Deductible, 40%

Pharmacy Benefits

Retail Pharmacy
- Preferred Generic Rx $10 Copay $10 Copay Not Covered
- Preferred Brand-Name Rx $30 Copay $30 Copay Not Covered
- Non-Preferred Rx $50 Copay $50 Copay Not Covered
- Value Plus Specialty Rx 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 30 Days 30 Days N/A
- Rx Formulary List Advanced Control Plan Advanced Control Plan Not Covered
Mail Order Pharmacy
- Preferred Generic Rx $20 Copay $20 Copay Not Covered
- Preferred Brand-Name Rx $60 Copay $60 Copay Not Covered
- Non-Preferred Rx $100 Copay $100 Copay Not Covered
- Value Plus Specialty Rx 30% Max $250 Copay 30% Max $250 Copay Not Covered
- Supply Limit 90 Days 90 Days N/A

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