Page 7 - Sample Fotokem.pub

Benefits

Medical Insurance

Aetna Aetna
PPO HSA PPO

Network Name Managed Choice Non-Network Managed Choice Non-Network
POS (Open Access) POS (Open Access)
Health Benefits
Life me Maximum Unlimited Unlimited

Deduc ble (Annual)
- Individual $750 $750 $2,600 $2,600
- Family $2,250 $2,250 $5,200 $5,200
Co-Insurance (Plan Pays) 90% 70% 90% 70%
Office Visit Copay
- Primary Care Physician $30 Copay Ded, 70% Ded, 90% Ded, 70%
- Specialist Office Visit $30 Copay Ded, 70% Ded, 90% Ded, 70%
Out-of-Pocket Maximum
- Individual $3,000 $6,000 $2,600 $5,000
- Family $6,000 $12,000 $5,200 $10,000
Hospitaliza on
- Inpa ent Ded, 90% Ded, 70% Ded, 90% Ded, 70%
- Outpa ent Ded, 90% Ded, 70% Ded, 90% Ded, 70%

Lab and X-Ray
- Diagnos c Ded, 90% Ded, 70% Ded, 90% Ded, 70%
- Complex Ded, 90% Ded, 70% Ded, 90% Ded, 70%
Emergency Services $100 Copay, 90% Ded, 90%
Urgent Care $20 Copay Ded, 70% Ded, 90% Ded, 70%

Preven ve Care 100% Ded, 70% 100% Ded, 70%
Chiroprac c $20 Copay Not Covered Ded, 90% Ded, 70%
20 Visits/Year 20 Visits/Year

Pharmacy Benefits
Pharmacy Deduc ble
- Individual $0 $0 Health Plan Deduc ble Applies
- Family $0 $0 Health Plan Deduc ble Applies

Retail Pharmacy
- Generic Formulary $15 Copay $15 Copay, 70% $10 Copay $10 Copay, 70%
- Brand Name Formulary $30 Copay $30 Copay, 70% $30 Copay $30 Copay, 70%
- Non-Formulary $50 Copay $50 Copay, 70% $50 Copay $50 Copay, 70%
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay Not Covered $20 Copay Not Covered
- Brand Name Formulary $60 Copay Not Covered $60 Copay Not Covered
- Non-Formulary $100 Copay Not Covered $100 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

7