| Benefits | Basic Managed Choice |
|---|---|
| You Pay | |
| Preventative Services | $0 |
| Office Visits Primary Care Physician (PCP) Specialist |
$30 PCP copay (after deductible)
$45 Specialist copay (after deductible) |
| Emergency | $100 copay (after deductible) |
| Urgent Care Facility | $100 copay (after deductible) |
| Deductible | $2,500 single $5,000 family |
| HCRA Fund | N/A |
| Deductible after HCRA Fund | N/A |
| Coinsurance | 35% |
| Annual Out-of-Pocket Maximum | $6,000 single $12,00 family |
Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible
| Benefits | Basic Managed Choice |
|---|---|
| You Pay | |
| Office Visits and Preventative Care |
Deductible and Coinsurance |
| Emergency | $100 copay (after deductible) |
| Deductible | $7,000 single $14,000 family |
| Coinsurance* | 50% |
| Annual Out-of-Pocket Maximum | $12,000 single $24,000 family |
* The plan pays out-of-network benefits based on Medicare reimbursement levels (up to 110% of Medicare for professional services and 140% for facility charges). In addition to your coinsurance, you are responsible for amounts that exceed these levels.
| Type of Drug | Definition |
|---|---|
| Generic | Drug with same active ingredients as brand name, with lower cost |
| Preferred Brand* | Drug marketed under a specific trademark or name by specific drug manufacturer and included on Aetna's drug list. |
| Non Preferred Brand* (No generic available) |
Drug marketed under a specific trademark or name by specific drug manufacturer and NOT included on Aetna's drug list. |
| Specialty Brand | High-cost prescription medications used to treat complex, chronic conditions |
* If you or your physician requests a brand-name medication when a generic is available, you will pay the applicable copay plus the difference between the cost of the generic and brand-name drug.