PPO Medical Plan

Below is a brief outline of the benefits provided in 2017. Refer to the official benefits plan booklet for a comprehensive description of plan benefits. Under all circumstances, the plan booklet will take precedence over information contained on this website.  The 2018 PPO plan booklet will be available by April 1, 2018.  Contact Aetna Concierge Services at (800) 836-2824 for questions of 2018 coverage.

Benefit

  In-Network Out-of-Network
Deductible $500 individual/$1,000 family
Annual Out of Pocket Max $3,350 individual/$6,700 family (includes deductible)
Lifetime maximum benefit Unlimited
Office Visits 100% after $25 copay Deductible/ Coinsurance

Preventive Care

  In-Network Out-of-Network
Immunizations  100% 60% after deductible
Routine adult physicals 100% 60% after deductible
Well-woman exams/ screenings 100% 60% after deductible
Well-baby exams 100% 60% after deductible

List of Preventive Services

Other Services

  In-NetworkOut-of-Network
Emergency Room
(copay waived if admitted)
$100 copay, then deductible/coinsurance
Inpatient hospital services 80% after deductible 60% after deductible
Outpatient hospital services 80% after deductible 60% after deductible
Outpatient surgical center 80% after deductible 60% after deductible

Prescription drugs (retail/pharmacy)

  30-day supply
Generic $10 copay
Brand formulary $30 copay
Nonformulary $60 copay

Prescription drugs (mail order)

 90-day supply  
Generic   $20 copay  
Brand formulary   $60 copay  
Nonformulary   $120 copay