Page 102 - Bird RFP Response_Burnham Benefits

AETNA
PLAN NAME PPO/OAMC

NETWORK NAME OPEN CHOICE PPO NETWORK NON-NETWORK*

Deductible (per calendar year)
Individual / Family $250 / $500 $500 / $1,000

Out-of-Pocket Maximum (per calendar year)
Individual / Family $2,250 / $4,500 $4,500 / $9,000

Covered Services
Office Visits (physician / specialist) $10 Copay 30% after deductible

Routine Preventive Care Covered 100% Not Covered

Teladoc $10 Copay Not Covered

Coinsurance (Plan Pays) 90% 70%

Outpatient Diagnostic Lab & X-Ray Covered 100% 30% after deductible
(physician’s office / other facility)

Complex Imaging 10% after deductible 30% after deductible
(physician’s office / other facility)

Emergency Room $100 Copay $100 Copay
(copay waived if admitted)

Urgent Care Facility $50 Copay 30% after deductible

Inpatient Hospital Stay 10% after deductible 30% after deductible

Outpatient Surgery 10% after deductible 30% after deductible

Chiropractic $10 Copay, 20 visits/year 30% after deductible

* Non-Network providers do not have a contract and therefore can charge you any amount. Aetna will reimburse you up to an allowed amount based on a % of Medicare.
You are responsible for any amount above the above the allowed amount, commonly known as balanced billing.