TRADITIONAL PPO PLAN $10/20%/40% 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 and Select Network Providers OUT NETWORK OF Aligned Providers $250 per member $750 per member $1,500 per member Deductible - per calendar year* $500 per family $1,500 per family $3,000 per family $20 copay $20 copay $35 copay Copays/Coinsurance Office visits Outpatient mental health Urgent Care Fixed Dollar Copays care visits $100 Outpatient mental health $30 copay Emergency room visits care visits $30 copay Office visits $200 $35 copay Specialist office visits Outpatient surgery facility – $35 Urgent Care fee only $40 Urgent care visits $1,000 copay Specialist office visits Inpatient admissions $100 $100 copay Emergency room visits $50 Emergency room visits Outpatient surgery facility Outpatient surgery – – fee only facility fee only $500 copay Inpatient admissions Percent Coinsurance 10% 20% 40% of R&C Out-of-Pocket Maximum per – calendar year* $2,500 per member $4,750 per member $9,500 per member Includes Prescription drugs, $5,000 per family $9,500 per family $19,000 per family deductible, coinsurance and copays Lifetime Maximum None Includes Prescription Drugs FULL (DOLLARS INTEGRATION ACCUMULATE TOWARDS ALL TIERS) FACILITY OUTPATIENT DIAGNOSTIC SERVICES TIER 1 Trinity Health facilities and TIER 2 TIER 3 Aligned Providers and Aligned Select Network Providers OUT NETWORK OF Providers MRI, MRA, PET and CAT Scans and Covered 90% after deductible Covered 80% after Covered 60% of R&C after – – – Nuclear Medicine deductible deductible Covered 90% after deductible Diagnostic Tests, X-rays, Covered 80% after Covered 60% of R&C after – – – Laboratory & Pathology deductible deductible Radiation Therapy Covered 90% deductible Covered 80% after Covered 60% of R&C after – – – deductible deductible
TRADITIONAL PPO PLAN $10/20%/40% 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 and Aligned Providers TIER 2 Select Network Providers TIER 3 OUT OF NETWORK Deductible - per calendar year* $250 per member $500 per family $750 per member $1,500 per family $1,500 per member $3,000 per family Copays/Coinsurance Fixed Dollar Copays $20 copay Office visits Outpatient mental health care visits $30 copay Specialist office visits $35 Urgent care visits $100 Emergency room visits $50 Outpatient surgery – facility fee only $20 copay Outpatient mental health care visits $30 copay Office visits $35 copay Urgent Care $40 Specialist office visits $100 copay Emergency room visits Outpatient surgery – facility fee only $500 copay Inpatient admissions $35 copay Urgent Care $100 Emergency room visits $200 Outpatient surgery – facility fee only $1,000 copay Inpatient admissions Percent Coinsurance 10% 20% 40% of R&C Out-of-Pocket Maximum – per calendar year* Includes Prescription drugs, deductible, coinsurance and copays $2,500 per member $5,000 per family $4,750 per member $9,500 per family $9,500 per member $19,000 per family Lifetime Maximum Includes Prescription Drugs None FULL INTEGRATION (DOLLARS ACCUMULATE TOWARDS ALL TIERS) FACILITY OUTPATIENT DIAGNOSTIC SERVICES TIER 1 Trinity Health facilities and Aligned Providers and Aligned Providers TIER 2 Select Network Providers TIER 3 OUT OF NETWORK MRI, MRA, PET and CAT Scans and Nuclear Medicine Covered – 90% after deductible Covered – 80% after deductible Covered – 60% of R&C after deductible Diagnostic Tests, X-rays, Laboratory & Pathology Covered – 90% after deductible Covered – 80% after deductible Covered – 60% of R&C after deductible Radiation Therapy Covered – 90% deductible Covered – 80% after deductible Covered – 60% of R&C after deductible
2018%20Traditional%20PPO_3_1_2018.docx