Below is a brief outline of the benefits provided in 2019. 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 2020 PPO plan booklet will be available by April 1, 2020. 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 |
List of Preventive Services
Other Services
| | In-Network | Out-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 |
