Page 7 - Trident EE Guide 01-18 OPTION 1
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BENEFITS
MEDICAL INSURANCE
Aetna Aetna
Plan Name HMO Value Plan HMO Full Plan
CA only CA only
Network Name AVN Full
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0
- Family $0 $0
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Primary Care Physician $25 Copay $25 Copay
- Specialist Office Visit $50 Copay $50 Copay
- Teladoc $50 Copay $50 Copay
Out-of-Pocket Maximum
- Individual $2,500 $2,500
- Family $5,000 $5,000
Hospitalization
- Inpatient $750 Copay $750 Copay
- Outpatient $200 Copay $200 Copay
Lab and X-Ray 100% 100%
- Complex $150 Copay $150 Copay
Emergency Services $150 Copay $150 Copay
Urgent Care $35 Copay $35 Copay
Preventive Care 100% 100%
Chiropractic $15 Copay $15 Copay
20 Visits/Year 20 Visits/Year
Pharmacy Benefits - Aetna Value Plus Open Formulary
Retail Pharmacy
- Generic Formulary $10 Copay $10 Copay
- Brand Name Formulary $30 Copay $30 Copay
- Non-Formulary $50 Copay $50 Copay
- Preferred & Non-Preferred Specialty Drugs 20% up to $200 20% up to $200
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $20 Copay $20 Copay
- Brand Name Formulary $60 Copay $60 Copay
- Non-Formulary $100 Copay $100 Copay
- Supply Limit 90 Days 90 Days
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