Page 7 - Fitness Together Benefit Guide 2020

BENEFITS

MEDICAL INSURANCE

AETNA
PLAN NAME HSA PPO PLAN

Network Managed Choice® POS (Open Access) Non-Network

Medical Benefits
Lifetime Maximum Unlimited
Deductible (Annual)
• Individual $3,000 $5,000
• Family $6,000 $10,000

Co-insurance (Plan Pays) 100% 50%*
Physician Office Visit
• Preventive Care 100%, ded waived 100%, ded waived
• Primary Care Physician Deductible, 100% Deductible, 50%
• Specialist Deductible, 100% Deductible, 50%
• Urgent Care Deductible, 100% Deductible, 50%
• Virtual Visits $40 copay until Ded, 100% Not Covered
Out of Pocket Maximum
• Individual $6,000 $10,000
• Family $12,000 $20,000

Hospitalization
• Inpatient Deductible, 100% Deductible, 50%
• Outpatient Surgery Deductible, 100% Deductible, 50%
• Physician Charges Deductible, 100% Deductible, 50%

Emergency Services Deductible, 100%
Lab and X-Ray Deductible, 100% Deductible, 50%
Chiropractic Deductible, 100% Deductible, 50%
Max 20 Visits/Year Max Combined
Mental Health
• Inpatient Deductible, 100% Deductible, 50%
• Outpatient Deductible, 100% Deductible, 50%
Prescription Drugs

Pharmacy Deductible Included in Medical Deductible
Retail (30 Day Supply)
• Value / Preferred Generic $3 / $10 Copay 30% after copay
• Preferred Brand Name $30 Copay 30% after copay
• Non-Preferred $50 Copay 30% after copay
• Specialty 10% up to $250 Not covered
Mail Order (90 Day Supply)
• Value / Preferred Generic $6 / $20 Copay Not Covered
• Preferred Brand Name $60 Copay Not Covered
• Non-Preferred $100 Copay Not Covered
• Specialty 10% up to $250 Not Covered

*Non-Network is paid based on what Medicare pays for these services. Doctors and Professionals: 105% of Medicare; Hospitals and other Facilities: 140% of
Medicare.

7