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HEALTH BENEFITS: MEDICAL PLAN OPTIONS HEALTH BENEFITS: MEDICAL PLAN OPTIONS

Aetna Aetna
OAMC POS Plan HSA Plan
Managed Choice Non-Network Managed Choice Non-Network
POS (Open Access) POS (Open Access)
Plan Provisions
Lifetime Maximum Unlimited Unlimited
Annual Deductible
Individual $750 $1,500 $2,000 $2,800
Family $1,500 $3,000 $4,000 $5,600
Coinsurance (Plan Pays) 80% 60% 80% 60%
Out-of-Pocket Maximum
Individual $3,000 $7,000 $4,000 $8,000
Family $6,000 $14,000 $8,000 $16,000
Medical Coverage
Physician Office Visit
PCP $20 Copay Ded, 40% Ded, 20% Ded, 40%
Specialist $40 Copay Ded, 40% Ded, 20% Ded, 40%

Hospitalization
Inpatient Ded, 20% Ded, 40% Ded, 20% Ded, 40%
Outpatient Surgery Ded, 20% Ded, 40% Ded, 20% Ded, 40%
Emergency Services $250 Copay, 20% Ded, 20%
Waived if Admitted
Urgent Care $50 Copay Ded, 40% Ded, 20% Ded, 40%
Preventive Care No Charge Not Covered No Charge Not Covered

Alternative Care
Chiropractic $40 Copay Ded. 40% Ded, 20% Ded, 40%
Max 20 Visits/Year Max 24 Visits/Year
Acupuncture $40 Copay Ded, 40% Ded, 20% Ded, 40%
Max 20 Visits/Year Max 20 Visits/Year
Prescription Drugs
Retail Pharmacy Plan Ded Applies
– Supply Limit 30 Days N/A 30 Days N/A
– Tier 1 $10 Copay Not Covered $10 Copay Not Covered
– Tier 2 $30 Copay Not Covered $20 Copay Not Covered
– Tier 3 $50 Copay Not Covered $50 Copay Not Covered
– Tier 4 30%, Max $250 Not Covered 30%, Max $250 Not Covered
Mail Order Pharmacy
– Supply Limit 90 Days N/A 90 Days N/A
– Tier 1 $20 Copay Not Covered $30 Copay Not Covered
– Tier 2 $60 Copay Not Covered $60 Copay Not Covered
– Tier 3 $100 Copay Not Covered $100 Copay Not Covered
– Tier 4 30%, Max $625 Not Covered 30%, Max $625 Not Covered

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