Page 7 - Alexander EE Guide 01-19 v3

BENEFITS

Medical Insurance

Meritain Health (Aetna) Meritain Health (Aetna)
Plan Name EPO POS

Network Name Aetna Choice POS II Aetna Choice POS II Non-Network
Health Benefits
Lifetime Maximum Benefit Unlimited Unlimited
Deductible (Calendar Year)
- Individual $250 $500 $1,000
- Family $750 $1,000 $2,000
Co-Insurance (Plan Pays) 80% 85% 60%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay Deductible, 40%
- Specialist Office Visit $50 Copay $40 Copay Deductible, 40%
Out-of-Pocket Maximum
- Individual $4,500 $3,500 $6,500
- Family $9,000 $7,000 $13,000

Hospitalization
- Inpatient Deductible, 20% Deductible, 15% Deductible, 40%
Max $800/Day
- Outpatient Deductible, 20% Deductible, 15% Deductible, 40%
Max $400/Day
Lab and X-Ray
- Diagnostic $10 Copay $10 Copay Deductible, 40%
Max $400
- Complex Deductible, 20% Deductible, 15% Deductible, 40%
Emergency Services Deductible, $150 Copay, 20% Deductible, $150 Copay, 15%
Urgent Care $50 Copay $40 Copay Deductible, 40%
Preventive Care No Charge No Charge 40%

Chiropractic $20 Copay $20 Copay Deductible, 40%
Max 60 Visits/Year Max 60 Visits/Year
Pharmacy Benefits

Pharmacy Deductible $200 $200 N/A
Retail Pharmacy (30 Day Supply)
- Generic Formulary $10 Copay $10 Copay Not Covered
- Brand Name Formulary Deductible, $25 Copay Deductible, $25 Copay Not Covered
- Non-Formulary Deductible, 50% Max $150 Deductible, $50 Copay Not Covered
- Preventive No Charge No Charge Not Covered
- Specialty Deductible, 50% Max $150 Deductible, $50 Copay Not Covered
Mail Order Pharmacy (90 Day Supply)
- Generic Formulary $20 Copay $20 Copay Not Covered
- Brand Name Formulary Deductible, $50 Copay Deductible, $50 Copay Not Covered
- Non-Formulary Deductible, 50% Max $300 Deductible, $100 Copay Not Covered
- Preventive No Charge No Charge Not Covered

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