Page 7 - Lake Avenue Church Benefits Guide 2020

Medical Benefits

Medical Insurance

Aetna Aetna Aetna
Plan Name DEDUCTIBLE HMO NO DED. HMO PPO
Network Name Value Network HMO Value Network HMO In-Network Non-Network
Health Benefits $500 $20/$40/80 RX3 $20/$40 RX3 POS $500 80/50 $30/40 RX3

Lifetime Maximum Benefit Unlimited Unlimited Unlimited

Deductible (Annual)
- Individual $500 $0 $500 $5,000
- Family $1,000 $0 $1,000 $10,000
Co-Insurance (Plan Pays) 80% 100% 80% 50%
Office Visit Copay
- Primary Care Physician $20 Copay $20 Copay $30 Copay Deductible, 50%
- Specialist Office Visit $40 Copay $40 Copay $30 Copay Deductible, 50%
- Online Visit $40 Copay $40 Copay $30 Copay N/A
Chiropractic/ Acupuncture $15 Copay $15 Copay $40 Copay Deductible, 50%
(Direct referral) 20 visits/year 20 visits/year
Out-of-Pocket Maximum
- Individual $3,000 $2,000 $4,000 $10,000
- Family $6,000 $4,000 $8,000 $20,000

Hospitalization
- Inpatient Deductible, 80% covered $500/admit $750/day (3 day) Deductible, 50%
- Outpatient Deductible, 80% $200 $750 Copay Deductible, 50%
Lab and X-Ray
- Office / Freestanding Lab 100% 100% (complex $100) $25 Copay Deductible, 50%
- Hospital $40 (complex $150) 100% (complex $100) $50 Copay Deductible, 50%
(complex $500)
Emergency Services Deductible, $150 $150/visit Deductible, $250 Copay
Urgent Care $50/visit $50/visit $50/visit Deductible, 50%

Preventive Care 100% 100% 100% Deductible, 50%

Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1a/1b Generic $10 $10 $10 Not Covered
- Tier 2 Brand Name $30 $30 $30 Not Covered
- Tier 3 Non-Formulary $50 $50 $50 Not Covered
- Tier 4 Specialty 30% to $250 30% to $250 30% to $250 Not Covered
- Supply Limit 30 Days 30 Days 30 Days N/A
Mail Order Pharmacy
- Tier 1a/1b Generic $20 $20 $20 Not Covered
- Tier 2 Brand Name $60 $60 $60 Not Covered
- Tier 3 Non-Formulary $100 $100 $120 Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A

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