Page 5 - NickCo Hospitality_2019 EE Benefits Guide_Hourly Associates_FINAL.2.pub
P. 5
BENEFITS
Medical Insurance
Plan Name Aetna HMO
Network Name Aetna Value Network (AVN)
Health Benefits
Life me Maximum Benefit Unlimited
Deduc ble (Annual)
‐ Individual $1,000
‐ Family $2,000
Office Visit Copay
‐ Primary Care Physician $30 Copay
‐ Specialist Office Visit $50 Copay
Out‐of‐Pocket Maximum
‐ Individual $4,000
‐ Family $8,000
Hospitaliza on
‐ Inpa ent Deduc ble, 30%
‐ Outpa ent Deduc ble, 30%
Emergency Services Deduc ble, $150
Ambulance Services (Emergency) $150 Copay
Urgent Care $50 Copay
Preven ve Care No Charge
Pharmacy Benefits Rx Deduc ble $150 Ind /$300 Fam
Retail Pharmacy
‐ Preferred Generic Rx $10 Copay
‐ Preferred Brand‐Name Rx Deduc ble, $40 Copay
‐ Non‐Preferred Rx Deduc ble, $60 Copay
‐ Value Plus Specialty Rx Deduc ble, 30% Max $250 Copay
‐ Supply Limit 30 Days
Mail Order Pharmacy
‐ Preferred Generic Rx $20 Copay
‐ Preferred Brand‐Name Rx Deduc ble, $80 Copay
‐ Non‐Preferred Rx Deduc ble, $120 Copay
‐ Value Plus Specialty Rx Deduc ble, 30% Max $250 Copay
‐ Supply Limit 90 Days
5
