Page 5 - NickCo Hospitality_2020 EE Benefits Guide_Hourly Associates
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BENEFITS
Medical Insurance
Plan Name Aetna HMO
Network Name Aetna Value Network (AVN)
Health Benefits
Lifetime Maximum Benefit Unlimited
Deductible (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
Hospitalization
- Inpatient Deductible, 30%
- Outpatient Deductible, 30%
Emergency Services Deductible, $150
Ambulance Services (Emergency) $150 Copay
Urgent Care $50 Copay
Preventive Care No Charge
Pharmacy Benefits Rx Deductible $150 Ind /$300 Fam
Retail Pharmacy
- Preferred Generic Rx $10 Copay
- Preferred Brand-Name Rx Deductible, $40 Copay
- Non-Preferred Rx Deductible, $60 Copay
- Value Plus Specialty Rx Deductible, 30% Max $250 Copay
- Supply Limit 30 Days
- Rx Formulary List Advanced Control Plan
Mail Order Pharmacy
- Preferred Generic Rx $20 Copay
- Preferred Brand-Name Rx Deductible, $80 Copay
- Non-Preferred Rx Deductible, $120 Copay
- Value Plus Specialty Rx Deductible, 30% Max $250 Copay
- Supply Limit 90 Days
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