PPO Medical Plan

Below is a brief outline of the benefits provided in 2020. 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.  Contact Aetna Concierge Services at (800) 836-2824 for questions of 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

 

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