ESSENTIAL ASSIST PPO PLAN (WITH HRA) SAINT HEALTH SYSTEM - – JOSEPH INDIANA $10/25%/50% RX PROVIDED AETNA LIFE INSURANCE COMPANY BY EFFECTIVE MARCH 1, 2018 AETNA INC. CPOS II – DEDUCTIBLE, COPAYS/COINSURANCE DOLLAR MAXIMUMS AND TIER 1 TIER 2 TIER 3 Trinity Health Facilities OUT OF NETWORK Select Health Network Aligned Select Health Facilities not in Tier 1 Network Facilities Aetna Network for Select Health Network Chiropractic health only Physicians & Advanced Practice Providers Aetna Network for behavioral health only $1,000 per member $2,500 per member $4,000 per member Deductible - per calendar year* $2,000 per family $5,000 per family $8,000 per family $850 single Employer Contribution $1,700 family $100 $100 copay $100 copay Copays/Coinsurance Emergency room visits Emergency room visits Emergency room visits Fixed Dollar Copays $50 copay $200 copay Outpatient surgery – Outpatient surgery facility facility fee only Outpatient surgery facility – – fee only $750 copay fee only $1,000 copay Inpatient admissions Inpatient admissions Percent Coinsurance 20% 30% 40% of R&C Out-of-Pocket Maximum per – calendar year* $3,500 per member $5,500 per member $9,000 per member Includes Pharmacy, deductible, $7,000 per family $11,000 per family $18,000 per family coinsurance and copays Lifetime Maximum None Includes Prescription Drugs FULL (DOLLARS INTEGRATION ACCUMULATE TOWARDS ALL TIERS) FACILITY OUTPATIENT DIAGNOSTIC SERVICES TIER 1 TIER 2 TIER 3 MRI, MRA, PET and CAT Scans and Covered 80% deductible Covered 70% after Covered 60% of R&C after – – – Nuclear Medicine deductible deductible Other Diagnostic Tests, X-rays, Covered 80% after deductible Covered 70% after Covered 60% of R&C after – – – Laboratory & Pathology deductible deductible Radiation Therapy Covered 80% after deductible Covered 70% Covered 60% of R&C – – – deductible deductible
ESSENTIAL ASSIST PPO PLAN (WITH HRA) – SAINT JOSEPH HEALTH SYSTEM - INDIANA $10/25%/50% RX PROVIDED BY AETNA LIFE INSURANCE COMPANY EFFECTIVE MARCH 1, 2018 – AETNA INC. CPOS II DEDUCTIBLE, COPAYS/COINSURANCE AND DOLLAR MAXIMUMS TIER 1 Trinity Health Facilities Aligned Select Health Network Facilities Select Health Network Physicians & Advanced Practice Providers Aetna Network for behavioral health only TIER 2 Select Health Network Facilities not in Tier 1 Aetna Network for Chiropractic health only TIER 3 OUT OF NETWORK Deductible - per calendar year* $1,000 per member $2,000 per family $2,500 per member $5,000 per family $4,000 per member $8,000 per family Employer Contribution $850 single $1,700 family Copays/Coinsurance Fixed Dollar Copays $100 Emergency room visits $50 copay Outpatient surgery – facility fee only $100 copay Emergency room visits Outpatient surgery – facility fee only $750 copay Inpatient admissions $100 copay Emergency room visits $200 copay Outpatient surgery – facility fee only $1,000 copay Inpatient admissions Percent Coinsurance 20% 30% 40% of R&C Out-of-Pocket Maximum – per calendar year* Includes Pharmacy, deductible, coinsurance and copays $3,500 per member $7,000 per family $5,500 per member $11,000 per family $9,000 per member $18,000 per family Lifetime Maximum Includes Prescription Drugs None FULL INTEGRATION (DOLLARS ACCUMULATE TOWARDS ALL TIERS) FACILITY OUTPATIENT DIAGNOSTIC SERVICES TIER 1 TIER 2 TIER 3 MRI, MRA, PET and CAT Scans and Nuclear Medicine Covered – 80% deductible Covered – 70% after deductible Covered – 60% of R&C after deductible Other Diagnostic Tests, X-rays, Laboratory & Pathology Covered – 80% after deductible Covered – 70% after deductible Covered – 60% of R&C after deductible Radiation Therapy Covered – 80% after deductible Covered – 70% deductible Covered – 60% of R&C deductible