Aetna
877-204-9186
Group Number: 237642
The Aetna Open Access Managed Care (PPO) plan offers employees the flexibility to see different doctors, whether or not they are in your plan’s network. High Deductible (HD) combines traditional medical coverage with a Health Savings Account (HSA). As evident by the name, this plan has a higher deductible members must reach before the plan kicks in.
|
Aetna OAMC PPo HD |
In-Network |
Out-Network |
|---|---|---|
| Annual Deductible | ||
| Individual | $2,000 | $4,000 |
| Individual within Family | $3,200 | $4,000 |
| Family | $4,000 | $8,000 |
| Annual Out of Pocket Maximum | ||
| Individual | $4,000 | $8,000 |
| Family | $8,000 | $16,000 |
|
Medical Services |
||
| Primary Care Visit | 10% | 30% |
| Specialist Office Visit | 10% | 30% |
| Basic X-ray and Laboratory | 10% | 30% |
| Inpatient Hospital | 10% | 30% |
| Emergency Room | 10% | 10% |
| Urgent Care | 10% | 30% |
| Chiropractic | 10% | 30% |
| Hearing Aid | 10% | 10% |
| Prescription Drugs | After Deductible | After Deductible |
| Generic / Tier 1 | $10 copay | Not Covered |
| Formulary / Tier 2 | $40 copay | Not Covered |
| Non-Formulary / Tier 3 | $50 copay | Not Covered |
| Specialty/ Tier 4 | 30% up to $300 copay | Not covered |
| Semimonthly Employee Contribution | |
|---|---|
| Employee Only | $86.82 |
| Employee + 1 | $295.45 |
| Employee + Family | $468.81 |
Plan Documents and Resources
Plan Documents