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BENEFITS

MEDICAL INSURANCE

Aetna Aetna PPO
Plan Name HMO Full Plan PPO Plan
AZ Only CA & Out-of-State

Network Name Full Open Access Non-Network
Managed Choice (OAMC)
Health Benefits
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $0 $500 $1,000
- Family $0 $1,000 $2,000
Co-Insurance (Plan Pays) 100% 80% 60%
Office Visit Copay
- Primary Care Physician $25 Copay $20 Copay Deductible, 40%
- Specialist Office Visit $50 Copay $20 Copay Deductible, 40%
- Teladoc $50 Copay $20 Copay N/A
Out-of-Pocket Maximum
- Individual $2,500 $2,000 $4,000
- Family $5,000 $4,000 $8,000

Hospitalization
- Inpatient $750 Copay Deductible, 20% Deductible, 40%
- Outpatient $200 Copay Deductible, 20% Deductible, 40%
Lab and X-Ray 100% Deductible, 20% Deductible, 40%
- Complex Imaging $150 Copay Deductible, 20% Deductible, 40%
Emergency Services $150 Copay $150 Copay, 20%
Urgent Care $35 Copay $35 Copay Deductible, 40%
Preventive Care 100% 100% Deductible, 40%

Chiropractic $15 Copay $20 Copay Deductible, 40%
20 Visits/Year 20 Visits/Year

Pharmacy Benefits - Aetna Value Plus Open Formulary
Retail Pharmacy
- Generic Formulary $10 Copay $10 Copay Not Covered
- Brand Name Formulary $30 Copay $40 Copay Not Covered
- Non-Formulary $50 Copay $60 Copay Not Covered
- Preferred & Non-Preferred Specialty Drugs 20% up to $200 20% up to $200 N/A
- Supply Limit 30 Days 30 Days N/A
Mail Order Pharmacy
- Generic Formulary $20 Copay $20 Copay N/A
- Brand Name Formulary $60 Copay $80 Copay N/A
- Non-Formulary $100 Copay $120 Copay N/A
- Supply Limit 90 Days 90 Days N/A

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