Page 6 - 5.11 Benefit Guide 2019 EXECUTIVE

MEDICAL

AETNA AETNA
HSA PLAN PPO PLAN
NETWORK Network Non-Network Network Non-Network
HEALTH BENEFITS

Lifetime Maximum Unlimited Unlimited
Annual Deductible
• Employee $2,000 $4,000 $1,250 $3,000
• Family $4,000 $8,000 $2,500 $6,000
5.11 HSA Annual Contribution
• Employee $500 None
• Employee + Spouse $750 None
• Employee + Children $750 None
• Employee + Family $1,200 None
Coinsurance (Plan Pays) 80% 50% 80% 50%
Physician Office Visit
• PCP Ded, 80% Ded, 50% $40 Copay Ded, 50%
• Specialist Ded, 80% Ded, 50% $50 Copay Ded, 50%
Out-of-Pocket Maximum Includes Deductible Includes Deductible
• Employee $4,200 $8,000 $5,000 $10,000
• Family $6,300 $12,000 $10,000 $20,000
Hospitalization
• Inpatient Ded, 80% Ded, 50% $150 Copay, Ded, 50%
Ded, 80%
• Outpatient Surgery Ded, 80% Ded, 50% Ded, 80% Ded, 50%
Emergency Services Ded, 80% $150 Copay, 80%
Urgent Care Ded, 80% Ded, 50% $50 Copay Ded, 50%
Preventive Care 100% Ded, 50% 100% Not Covered
Chiropractic Ded, 80% Ded, 50% $50 Copay Ded, 50%
Max 20 Visits/Year Max 20 Visits/Year
PHARMACY BENEFITS
Annual Deductible Applies to Brand/Non-Formulary
• Employee Health Deductible Applies $100
• Family Health Deductible Applies $300
Retail (30 Day Supply)
• Generic $10 Copay Ded, Copay+50% $10 Copay Copay+50%
• Brand Name $25 Copay Ded, Copay+50% $30 Copay Copay+50%
• Non-Formulary $40 Copay Ded, Copay+50% $50 Copay Copay+50%
Mail Order (90 Day Supply)
• Generic $20 Copay Not Covered $20 Copay Not Covered
• Brand Name $50 Copay Not Covered $60 Copay Not Covered
• Non-Formulary $80 Copay Not Covered $100 Copay Not Covered

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