PLAN DESIGNS AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC
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1 Aetna Pharmacy Management Custom RX PLAN FEATURES Deductible (per calendar year) $250 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance 15% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $5,000 Includes deductible. Certain other member cost sharing elements may not apply towards the Payment Limit. Lifetime Maximum Primary Care Physician Selection Referral Requirements Unlimited except for where otherwise indicated Not Applicable None PREVENTIVE CARE Routine Physical Exams/Immunizations Covered 100% (One annual exam/pneumonia, Flu, Hepatitis B) Routine Gynecological Care Exams Covered 100% One Routine GYN visit and pap smear every 365 days Routine Mammograms Covered 100% One baseline mammogram for members 35-39; and one annual mammogram for members age 40 and over Routine Digital Rectal Exams / Prostate Specific Covered 100% Antigen Test For males age 40 and over. Colorectal Cancer Screening Covered 100% For all members 50 and over. Bone Density Testing Covered 100% Routine Eye Exam Covered 100% One annual exam. 11/03/2008 1
2 Routine Hearing Screening Covered 100% One (1) annual exam Hearing Aid Reimbursement $500 every 36 months PHYSICIAN SERVICES Primary Care Physician Visits (Office hours) 15% (After Office Hours) 15% Specialist Office Visits 15% Allergy Testing/Treatment 15% For initial testing by a specialist; with or without physician encounter DIAGNOSTIC PROCEDURES Diagnostic Laboratory and X-Ray 15% EMERGENCY MEDICAL CARE Urgent Care Provider $35 copay Emergency Room; Worldwide (waived if $50 copay admitted) Ambulance 15% HOSPITAL CARE Inpatient Coverage 15% The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Outpatient Surgery 15% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. MENTAL HEALTH SERVICES Inpatient Mental Illness 15% (Combined with Inpatient Substance Abuse) 190 Lifetime days The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Outpatient Mental Illness 15% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. ALCOHOL/DRUG ABUSE SERVICES Inpatient Substance Abuse (Detox and Rehab) 15% (Combined with Inpatient Mental Health) 190 Lifetime days The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. 11/03/2008 2
3 Outpatient Substance Abuse (Detox and Rehab) 15% The member cost sharing applies to covered benefits incurred during a member's outpatient visit. OTHER SERVICES Skilled Nursing Facility 0% per day - days 1-20; 15% per day - days (100 days per Medicare benefit period) The member cost sharing applies to covered benefits incurred during a member's inpatient stay. Home Health Care Covered 100% Hospice Care Covered by Medicare at a Medicare certified hospice Outpatient Short-Term Therapy (speech, physical, 15% cardiac and occupational) Chiropractic Care 15% For manual manipulation of the spine to the extent covered by Medicare Durable Medical Equipment/Prosthetic Devices 15% Podiatry 15% Limited to Medicare covered benefits only Diabetic Supplies Covered 100% Includes test strips, lancets and glucometer Outpatient Complex Radiology 15% Outpatient Dialysis 15% Vision Eyewear Allowance Coaching Lens discounts where available Included 11/03/2008 3
4 PRESCRIPTION DRUG BENEFITS Prescription drug calendar year Deductible TROOP Member cost sharing once Out of Pocket provision is reached* Retail Copayments Up to a 30-day supply at indicated copay Mail Order through Aetna Rx Home Delivery - Copayments None $4,350 0% $10 for Generic $20 for Preferred Brand $40 for Non-Preferred Brand $20 for Generic $40 for Preferred Brand $80 for Non-Preferred Brand Up to a three month (90-day) supply available via our preferred vendor, Aetna Rx Home Delivery. Requirements: Precertification Step-Therapy Formulary Mandatory Generic (MG) Prescription Options and Exclusions Anti-Obesity Drugs/Appetite Suppressants Contraceptives (covered whether or not medically necessary) Cosmetic Drugs Diabetic Supplies Restriction Yes Yes Open Yes All Contraceptives Covered Covers needles and syringes without purchase of insulin (separate copay applies to each purchase) 11/03/2008 4
5 Fertility Drugs, Oral and Injectable Performance Enhancement/Lifestyle Drugs Smoking Cessation Aids Imitrex Quantity Limit and Kit Logic Included Maximum 48 kits per year with one copay per kit. * This is a richer benefit than CMS PDP. After $4,350 out of pocket max, CMS PDP member cost sharing is the Greater of 5% or $2.40 generic/$6.00 all other covered medications. Disclaimers This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are provided by Aetna Life Insurance Company. MA Only Please refer to the plan documents (Evidence of Coverage) for a complete listing of benefits, exclusions and limitations. The following is a partial listing of exclusions and limitations under the Aetna Medicare Open Plan: 11/03/2008 5
6 Services that are not medically necessary or covered under the Original Medicare Program unless otherwise noted Plastic or cosmetic surgery unless medically necessary Custodial care Experimental procedures or treatments beyond Original Medicare limits Routine foot care that is not medically necessary Outpatient Prescription Drugs except those covered under Medicare Part B This material is for informational purposes only. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Aetna does not provide care or guarantee access to health services. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Discount Programs provide access to discounted prices and are not insured benefits. While this material is believed to be accurate as of the print date, it is subject to change. Benefits coverage is provided by Aetna Life Insurance Company, a Medicare Advantage organization, with a Medicare contract and benefits, limitations, service areas and premiums subject to change on January 1 of each year. You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. Your doctor or hospital must agree to accept the plan s terms and conditions prior to providing healthcare services to you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may not provide healthcare services to you, except in emergencies. Providers can find the plan s terms and conditions on our website at: 11/03/2008 6
PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC PLAN FEATURES
PLAN FEATURES Deductible (per calendar year) $0 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance Applies to all expenses unless otherwise
More informationPLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY INC. Cost Share. $0 Deductible. Unlimited
PLAN FEATURES Deductible (per calendar year) $0 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member Coinsurance Applies to all expenses unless otherwise
More informationPARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
PLAN FEATURES Deductible (per calendar year) $100 Deductible Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Annual Maximum Out-of-pocket (includes Deductible) $1,300
More information$0 $0 N/A. Pneumococcal, Flu, Hepatitis B Not Not Covered Routine GYN Care (Cervical and Vaginal Cancer Screenings)
PLAN FEATURES Network Providers Out-of-Network Providers Combined In and Out of Network Deductible (Plan Level/includes Network Deductible) $0 $0 Member Coinsurance Applies to all expenses unless otherwise
More informationPLAN DESIGN & BENEFITS. $100 Individual/$200 Family $500 Individual/$1000 Family
PLAN FEATURES Deductible (per calendar year) Provider None $1000 Individual/$2000 Family Deductible (per calendar year) Facility Level A: Level B: $100 Individual/$200 Family $500 Individual/$1000 Family
More information$300 $300. Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
PLAN FEATURES Network Providers Out-of-Network Providers Combined In and Out of Network Deductible (Plan Level/includes Network Deductible) $300 $300 Unless otherwise indicated, the Deductible must be
More informationPLAN DESIGN AND BENEFITS - NYC Community Plan SM 6-11 PARTICIPATING PROVIDER REFERRED*
Aetna Health Inc. for Referred Benefits Plan Effective Date: 10/1/2011 PLAN FEATURES Deductible (per calendar ) $5,000 Individual $15,000 Family Unless otherwise indicated, the Deductible must be met prior
More informationBenefits, Value Added Services and Premiums are effective January 1, 2015 through December 31, 2015
PLAN FEATURES Combined In and Out of Network Deductible (Plan Level/includes Network Deductible) Network Providers $0 Out-of-Network Providers $0 Member Coinsurance N/A Applies to all expenses unless otherwise
More informationNot applicable Optional. CHE PREFERRED CARE (Home Host) Covered 100%
PLAN FEATURES Catholic Health East PROVIDED BY LIFE INSURANCE COMPANY Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $6,700 The maximum out-of-pocket limit applies to all
More informationBenefits and Premiums are effective January 01, 2017 through December 31, 2017 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2017 through December 31, 2017 PLAN FEATURES Network & Out-of- Annual Deductible $300 This is the amount you have to pay out of pocket before the plan will
More informationNot applicable. Immunizations 1 exam per 12 months for members age 18 to age 65; 1 exam per 12 months for adults age 65 and older.
PLAN FEATURES NON- Deductible (per calendar year) $300 Employee $600 Employee $900 Family $1,800 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
More informationBenefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $3,400 The maximum out-of-pocket limit applies to all
More informationUniversity of Maine Aetna Medicare SM Plan (PPO) Medicare (C02) PPO Plan Custom Rx $10/$25/$40
Member Coinsurance 10% Applies to all expenses unless otherwise stated. Annual Maximum Out-of- $1,500 Pocket Amount (includes deductible) University of Maine PLAN FEATURES Combined In and Out of Network
More informationPLAN DESIGN AND BENEFITS - PA POS COST-SHARING 3.4 ($1,500 DED) PARTICIPATING PROVIDERS. $1,500 Individual
Plan Coinsurance * Out-of-Pocket Maximum (per calendar year, includes deductible) $3,000 Individual $6,000 Family 50% $6,000 Individual $12,000 Family Amounts over the Recognized Charge, failure to pre-certification
More informationPLAN DESIGN AND BENEFITS - PA POS COST-SHARING NO-REFERRAL 4.4 ($2,000 DED) $2,000 Individual
Plan Coinsurance * Out-of-Pocket Maximum (per calendar year, includes deductible) $4,000 Individual $8,000 Family 50% $8,000 Individual $16,000 Family Amounts over the Recognized Charge, failure to pre-certification
More informationBenefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Combined Annual Maximum Out-of-Pocket Amount (Plan Level / includes deductible) Annual Maximum
More informationCA HMO Deductible $1,500 70%
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
More informationBenefits and Premiums are effective January 01, 2017 through December 31, This is what you pay for Network & Out-of-Network Providers $0
Benefits and Premiums are effective January 01, 2017 through December 31, 2017 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES Network & Out-of-Network Annual Deductible
More informationPLAN DESIGN AND BENEFITS - IN MANAGED CHOICE POS OPEN ACCESS 90/60/60 $1,000 PREFERRED CARE
PLAN FEATURES NON- Deductible (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
More informationPLAN DESIGN AND BENEFITS MC Open Access Plan 1913
PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year) $1,500 Individual $4,500 Family $4,000 Individual $12,000 Family Unless otherwise indicated, the Deductible must be met prior
More informationLourdes Health System Proposed Effective Date: Aetna Helathfund Aetna Choice POS ll - ASC Salary Band: Less than $21,000 to $41,999
PROVIDED BY LIFE INSURANCE COMPANY FUND FEATURES HealthFund Amount $750 Employee $1,500 Employee + Spouse $1,500 Employee + Child(ren) $1,500 Family Amount contributed to the Fund by the employer Fund
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More informationPLAN DESIGN AND BENEFITS - PA POS HSA COMPATIBLE NO-REFERRAL 2.4 ($2,500 Ded) PARTICIPATING PROVIDERS
PLAN FEATURES Deductible (per plan year) $2,500 Individual NON- $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All
More informationCHE PREFERRED CARE (Home Host)
PLAN FEATURES Catholic Health East PROVIDED BY LIFE INSURANCE COMPANY Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family
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PLAN FEATURES Deductible (per plan year) $3,500 Individual $7,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The Individual Deductible can only be met
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Florida 2-100 Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS MC OA Plan 12-3000A-50 PLAN FEATURES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS
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Florida 2-100 Health Network Option (POS Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOption Plan 12-2000-70 PLAN FEATURES PARTICIPATING PROVIDERS
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Florida 2-100 Open Access Managed Choice Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN FEATURES PREFERRED PROVIDERS NON-PREFERRED PROVIDERS Deductible (per calendar year) PLAN DESIGN
More informationEnrollment Packet. Your guide to getting more out of your plan. Visit
Enrollment Packet Your guide to getting more out of your plan Visit http://www.aetnaretireeplans.com Throughout this kit, you ll see quick response (QR) codes. You scan them using your smartphone and they
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PLAN FEATURES Deductible (per calendar year) $5,000 Individual $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward
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PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered expenses accumulate toward the preferred and non-preferred
More informationPLAN DESIGN AND BENEFITS - New York Open Access MC 3-11 HSA Compatible
PLAN FEATURES Deductible (per plan year) $3,000 Individual $6,000 Individual $6,000 Family $12,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
More informationPARTICIPATING PROVIDERS / REFERRED Deductible (per calendar year)
Your HMO Plan Primary Care Physician - You choose a Primary Care Physician. The Aetna HMO Deductible provider network gives you access to a wide selection of Primary Care Physicians ( PCP's) and Specialists
More informationVersion: 15/02/2017 [ TPID: ] Page 1
PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not required Deductible (per calendar year) $1,500 Individual $3,000 Family $3,000 Individual $9,000 Family
More informationFlorida Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012
Florida 2-100 Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan 12-1500-Compass PLAN FEATURES Deductible (per calendar
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Aetna Life Insurance Company Texas Small Group MC Open Access Plan Effective Date: 09/01/2008 PLAN FEATURES NON- Deductible (per calendar year) $3,000 Individual $6,000 Individual $6,000 Family $12,000
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PLAN FEATURES Deductible (per calendar year) $100 Individual $200 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Pharmacy expenses do not apply towards the
More informationNorth Carolina Small Group Indemnity Aetna Life Insurance Company Plan Effective Date: 10/01/2010
PLAN FEATURES [Deductible (per calendar year) $1,000 Individual $3,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for for prescription
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Aetna Life Insurance Company Texas Small Group MC Open Access Plan Effective Date: 11/01/2008 PLAN FEATURES Deductible (per calendar year) $1,000 Individual $3,000 Individual $3,000 3 Individuals per $9,000
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Florida 2-100 Health Network Only (HMO Open Access) Aetna Life Insurance Company Plan Effective Date: 03/01/2012 PLAN DESIGN AND BENEFITS HNOnly Plan 12-1500-80 HSA PLAN FEATURES Deductible (per calendar
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY CHE PREFERRED CARE (Home Host)
PLAN FEATURES PROVIDED BY LIFE INSURANCE COMPANY CHE NON- Deductible ( year) None Individual $200 Individual $500 Individual None Family $400 Family $1,000 Family All covered expenses accumulate toward
More informationCovered 100% 20% 1 exam per 12 months for members age 18 and older.
PLAN FEATURES NON- Deductible (per calendar year) $1,200 Individual $2,000 Individual $3,600 Family $6,000 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred
More informationPlan changes are in red In-Network 2015 Out-of-Network
General Information Lifetime Maximum Benefit Unlimited Unlimited Annual Maximum Benefit Unlimited Unlimited Coinsurance Percentage 80.00% 50.00% Precertification Requirements Precertification Penalty Covered
More informationUnlimited/ $1,000,000 per lifetime Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Member Coinsurance Out-of-Pocket Maximum $1,500 $3,000 Individual (per calendar year) $3,000 $6,000 Family Member cost sharing for
More informationIL Small Group MC Open Access Aetna Life Insurance Company Plan Effective Date: 04/01/2009 PLAN DESIGN AND BENEFITS- MC $1,500 80/50/50 (04/09)
PLAN FEATURES Deductible (per calendar ) $1,500 Individual $3,000 Individual $4,500 Family $9,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. All covered
More information90% after deductible. Unlimited except where otherwise indicated. Primary Care Physician Selection. Unlimited except where otherwise indicated.
PLAN FEATURES Deductible (per calendar year) $150 Individual $575 Individual $300 Family $1,725 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost
More informationAll covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $250 per member (2-member maximum) Unless otherwise indicated, the
More informationNETWORK CARE. $4,500 Individual. (2-member maximum)
PLAN FEATURES Network Open Choice PPO Primary Care Physician Selection Deductible (per calendar year) Not Applicable $750 per member Not Applicable $750 per member (2-member maximum) (2-member maximum)
More informationAll covered expenses accumulate separately toward the Network and Out-of-Network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Deductible (per calendar year) Not Applicable $500 per member Not Applicable $500 per member (2-member maximum) (2-member
More informationNETWORK CARE. $4,500 (2-member maximum)
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $4,500 (2-member maximum) Unless otherwise indicated, the Deductible
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More informationPREFERRED CARE. Covered 100%; deductible waived Not Covered
PLAN FEATURES NON- Deductible (per calendar year) $1,300 Individual $1,300 Individual $2,600 Family $2,600 Family All covered expenses including prescription drugs accumulate toward both the preferred
More informationNETWORK CARE. $250 per member (2-member maximum)
PLAN FEATURES Network Managed Choice POS (Open Access) Primary Care Physician Selection Not Applicable Deductible (per calendar year) $250 per member (2-member maximum) Unless otherwise indicated, the
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PLAN FEATURES Deductible (per calendar year) $2,500 Single Subscriber $5,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The Single Subscriber Deductible
More informationUnlimited except where indicated. Unlimited except where indicated. Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) $500 Individual $1,250 Individual $1,000 Family $2,500 Family All covered expenses excluding prescription drugs accumulate toward both the preferred and non-preferred
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PLAN FEATURES OUT-OF- Deductible (per calendar year) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable.
More information$4,000 Family. $7,150 Individual $14,300 Family
PLAN DESIGN AND BENEFITS - CA Silver Basic HMO 2000 (01/17) (2017) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable
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PLAN DESIGN Customer Name: Caltech Proposed Effective Date: 01-01-2019 Plan: Low Option OAMC Organization Name: Aetna PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $3,950 Individual
More informationPLAN DESIGN AND BENEFITS - NJ POS HSA COMPATIBLE NO-REFERRAL 3.1 CALYR (OVR50%/UND50%) $2,500 Single Subscriber
PLAN FEATURES Deductible (per calendar year) $2,500 Single Subscriber $5,000 Single Subscriber $5,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being
More information15% 30% $7,350 Individual Unlimited Individual (per calendar year) Out-Of-Pocket Maximum
PLAN FEATURES Deductible (per calendar year) $1,750 Individual $20,000 Individual $3,500 Family $40,000 Family All covered expenses accumulate toward both the preferred and non-preferred Deductible. Unless
More informationPLAN DESIGN AND BENEFITS - Choice POS % - 08 PARTICIPATING PROVIDERS. $1,500 Individual $4,500 Family
Aetna Health Inc Texas Small Group Open Access Plan Effective Date: 11/01/2008 PLAN FEATURES Deductible (per calendar year) PARTICIPATING $1,500 Individual $4,500 Family $3,000 Individual $9,000 Family
More informationCovered 100%; deductible waived 40%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $1,000 Individual $1,500 Family $3,000 Family All covered expenses accumulate simultaneously toward both the preferred
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $500 None Family $1,500 All covered expenses accumulate separately toward the non-preferred Deductible. Unless otherwise
More information20% After deductible PREFERRED CARE. Covered 100%; deductible waived
PLAN FEATURES Deductible (per calendar year) $1,500 Individual $1,500 Individual $3,000 Family $3,000 Family All covered expenses, including nonpreventive prescription drugs, accumulate toward both the
More informationMEMBER COST SHARE. 20% after deductible
PLAN FEATURES Network Not Applicable Primary Care Physician Selection Not Applicable Deductible (per calendar year) $500 Individual (2-member maximum) Unless otherwise indicated, the Deductible must be
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PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $250 Individual None Family $500 Family All out-of-network covered expenses accumulate separately toward the non-preferred
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North Carolina PPO (Mandated 1 Life Plan) PLAN DESIGN AND BENEFITS Standard PPO Plan PLAN FEATURES PARTICIPATING Deductible (per plan year) $500 Individual $1,000 Individual $1,500 Family $3,000 Family
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Benefits Overview 2016 Drug Copayments $10 $20 $35 Medicare PPO Blue (PPO) Medicare PPO Blue (PPO) is a Medicare Advantage plan from Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross
More information$250 per member. All covered expenses accumulate separately toward the Network and Out-of-network Coinsurance Maximum.
PLAN FEATURES Network Managed Choice POS (Open Access) OUT-OF- Not Applicable Primary Care Physician Selection Deductible (per calendar year) Not Applicable $250 per member Not Applicable $250 per member
More informationPLAN DESIGN & BENEFITS MEDICAL PLAN PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $1,000 Individual $1,000 Family $2,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
More information$14,000 Family. $7,000 Individual. $14,000 Family
PLAN DESIGN AND BENEFITS - NV Bronze PPO 7000 100/70 (2017) NV Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
More informationCovered 100%; deductible waived 40%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $300 Individual $300 Individual $900 Family $900 Family All covered expenses accumulate separately toward the preferred or non-preferred
More informationWA Bronze PPO Saver /50 (1/14)
PLAN FEATURES Deductible (per calendar year) Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Member cost sharing for certain services, including member cost sharing
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) None Individual $600 Individual None Family $1,200 Family All out of network covered expenses accumulate towards the non-preferred
More information$15 copay $25 copay. - Silver&Fit copays are not included in the Annual Out-Of- Pocket Maximum
Prepared for Dundee Central School Effective: 01/01/2018 Plan Feature Highlights Annual deductible None $250 Annual out-of-pocket maximum (medical services only, does not include prescription drugs) $1,250
More informationUnlimited unless otherwise indicated.
PLAN FEATURES PARTICIPATING NON-PARTICIPATING Deductible (per calendar year) $1,000 Individual $5,000 Individual $2,000 Family $10,000 Family Unless otherwise indicated, the Deductible must be met prior
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH INC. AND AETNA HEALTH INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible $2,500 Individual $5,000 Individual (per calendar year) $5,000 Family $10,000 Family Unless otherwise indicated, the deductible must be met prior to benefits
More informationPLAN DESIGN AND BENEFITS - CT TC HSA Compatible / A 51+
PLAN FEATURES Deductible (per calendar year) $3,000 Individual $6,000 Family Unless otherwise indicated, the Deductible must be met prior to benefits being payable. The Individual Deductible can only be
More informationSchedule of Benefits (GR-9N-S DE)
Schedule of Benefits (GR-9N-S-01-001-01 DE) Plan Sponsor: The Church of Jesus Christ of Latter-Day Saints-Senior Missionaries Group Policy Number: 840232 Issue Date: June 3, 2013 Effective Date: August
More information$15 copay $25 copay. in a specialist office. - Silver&Fit copays are not included in the Annual Out-Of- Pocket Maximum
Prepared for Genesee Area Healthcare Plan Effective: 01/01/2019 Plan Feature Highlights Annual deductible None $250 Annual out-of-pocket maximum (medical services only, does not include prescription drugs)
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
Proprietary PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $750 Individual $20,000 Individual $2,000 Family $40,000 Family All covered expenses accumulate simultaneously toward
More information$7,000 Individual $14,000 Family
PLAN DESIGN AND BENEFITS - CA Gold AVN HMO 20 (01/17) (2017) CA Group Business 1-100 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Required Not applicable Deductible
More informationCovered 100%; deductible waived 30%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $500 Individual $1,000 Family $1,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
More information$4,000 Family. $6,350 Individual $12,700 Family
PLAN DESIGN AND BENEFITS - PA Silver PPO 2000 100/50 (2015) PA Group Business 1-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not applicable Not applicable
More informationCovered 100%; deductible waived 50%; after deductible. Covered 100%; deductible waived 50%; after deductible
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,500 Individual $4,500 Individual $3,000 Family $9,000 Family All covered expenses accumulate simultaneously toward both the preferred
More informationPLAN DESIGN & BENEFITS ADMINISTERED BY AETNA HEALTH INSURANCE COMPANY - SELF-FUNDED
PLAN FEATURES Deductible (per calendar year) $100 Individual $200 Family Unless otherwise indicated, the deductible must be met prior to benefits being payable. Member cost sharing for certain services,
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family All covered expenses, accumulate separately toward the preferred or
More informationQualified High Deductible Health Plan PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY - SELF FUNDED
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $6,600 Individual $20,000 Individual $13,200 Family $40,000 Family All covered expenses accumulate simultaneously toward both the
More information$8,000 Family. $6,000 Individual $12,000 Family
PLAN DESIGN AND BENEFITS - FL Silver HNOnly 4000 100 (2016) FL Group Business 2-50 Employees PLAN FEATURES NETWORK CARE OUT-OF-NETWORK CARE Primary Care Physician Selection Not required Not applicable
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per year) $1,500 Individual $3,000 Individual $3,000 Family $6,000 Family All covered expenses accumulate separately toward the preferred or non-preferred
More information