Page 11 - Work Life and Benefits Booklet 2020 SDC EDC

PLAN NAME AETNA AETNA AETNA AETNA
DED HMO FULL HMO OAMC/PPO PPO/HSA
DEDUCTIBLE HMO HMO OPEN ACCESS OPEN ACCESS
NETWORK NAME NETWORK NETWORK MANAGED CHOICE NON-NETWORK* MANAGED CHOICE NON-NETWORK*
CA ONLY CA ONLY NETWORK NETWORK
Deductible (per calendar year)
Individual / Family $100 / $200 None $250 / $500 $500 / $1,000 $1,400 / $2,800 $2,800 / $5,600
Out-of-Pocket Maximum (per calendar year)
Individual / Family $1,500 / $3,000 $1,500 / $3,000 $2,250 / $4,500 $4,500 / $9,000 $3,000 / $6,000 $8,000 / $16,000
Covered Services

Office Visits (physician / specialist) $10 Copay / $15 Copay / $20 Copay Deductible, 30% Deductible, 10% Deductible, 30%
$30 Copay
$30 Copay
Routine Preventive Care Covered 100% Covered 100% Covered 100% Not Covered Covered 100% Deductible, 30%
Teladoc $30 Copay $30 Copay $20 Copay Not Covered Deductible, 10% Not Covered
Coinsurance (Plan Pays) 100% 100% 90% 70% 90% 70%
Outpatient Diagnostic Lab & X-Ray Covered 100% Covered 100% Covered 100% Deductible, 30%
(physician’s office / other facility) Deductible, 10% Deductible, 30%
Complex Imaging
(physician’s office / other facility) Covered 100% $100 Copay Covered 100% Deductible, 30% Deductible, 10% Deductible, 30%
Emergency Room $150 Copay after $150 Copay $100 Copay $100 Copay Deductible, 10% Deductible, 10%
(copay waived if admitted) Deductible
Urgent Care Facility $10 Copay $10 Copay $50 Copay Deductible, 30% Deductible, 10% Deductible, 30%
No Charge after $150/Day for the
Inpatient Hospital Stay Deductible First 3 Days, then Deductible, 10% Deductible, 30% Deductible, 10% Deductible, 30%
Covered 100%

Outpatient Surgery No Charge after $100 Copay Deductible, 10% Deductible, 30% Deductible, 10% Deductible, 30%
Deductible
Chiropractic (20 visits/year) $10 Copay $15 Copay $20 Copay Deductible, 30% Deductible, 10% Deductible, 30%

* 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 percentage of
Medicare. You are responsible for any amount above the above the allowed amount, commonly referred to as balanced billing.