Page 10 - Work Life and Benefits Booklet 2018 - SW.pub
P. 10

NON-NETWORK*   $500 / $1,000   $4,500 / $9,000   30% after deductible   Not Covered   Not Covered   70%   30% after deductible   30% after deductible   $100 Copay   30% after deductible   30% after deductible   30% after deductible   30% after deductible










                  Medical Plan Highlights



                          AETNA   PPO/OAMC








                                  OPEN CHOICE PPO NETWORK   $250 / $500   $2,250 / $4,500   $10 Copay   Covered 100%   $10 Copay   90%   Covered 100%   10% after deductible   $100 Copay   $50 Copay   10% after deductible   10% after deductible   $10 Copay, 20 visits/year  * Non-Network providers do not have a contract and therefore can charge you any amount. Aetna will reimburse you up to an allowed amount based on a % of Medicare.






















                                                                                                               You are responsible for any amount above the above the allowed amount, commonly known as balanced billing.



















                             PLAN NAME   NETWORK NAME   Deductible (per calendar year)     Individual / Family  Out-of-Pocket Maximum (per calendar year)     Individual / Family   Covered Services   Office Visits (physician / specialist)   Routine Preventive Care   Coinsurance (Plan Pays)  Outpatient Diagnostic Lab & X-Ray  (physician’s office / other facility)   Complex Imaging  (physician’s office / other facility)   Emergency Room   (copay waived if admitted)   Urgent Care Facility   In







                                                                  Teladoc
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