HEALTH SAVINGS PPO PLAN (WITH HSA) SAINT HEALTH SYSTEM - – JOSEPH INDIANA PROVIDED AETNA LIFE INSURANCE COMPANY BY EFFECTIVE MARCH 1, 2018 AETNA INC. CPOS II – DEDUCTIBLE, COPAYS/COINSURANCE DOLLAR MAXIMUMS AND TIER 1 Trinity Health Facilities TIER 2 TIER 3 Aligned Select Health Select Health Network OUT NETWORK OF Network Facilities Facilities not in Tier 1 Select Health Network Aetna Network for Physicians & chiropractic health only Advanced Practice Providers Aetna Network for behavioral health only $1,500 per member $2,500 per member $3,500 per member Deductible - per calendar year* $3,000 per family $5,000 per family $7,000 per family $650 single Employer Contribution $1,300 family *amount prorated based upon date of eligibility No copays $100 copay $200 copay Copays/Coinsurance Outpatient surgery Outpatient surgery facility – – Fixed Dollar Copays facility fee only fee only $500 copay $1,000 copay Inpatient admissions Inpatient admissions Percent Coinsurance 10% 20% 40% of R&C Out-of-Pocket Maximum per – calendar year* $2,600 per member $5,000 per member $7,000 per member Includes Prescription drugs, $5,200 per family $10,000 per family $14,000 per family deductible, coinsurance and copays If any individual in the plan reaches the single out-of-pocket expenses before the family out-of-pocket maximum is met, the cost of that individual’s in-network, eligible care will be covered for the rest of the plan year. 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 Covered 90% after deductible Covered 80% after Covered 60% of R&C after – – – and Nuclear Medicine deductible deductible Covered 90% after deductible Other 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
HEALTH SAVINGS PPO PLAN (WITH HSA) – SAINT JOSEPH HEALTH SYSTEM - INDIANA 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* $1,500 per member $3,000 per family $2,500 per member $5,000 per family $3,500 per member $7,000 per family Employer Contribution $650 single $1,300 family *amount prorated based upon date of eligibility Copays/Coinsurance Fixed Dollar Copays No copays $100 copay Outpatient surgery – facility fee only $500 copay Inpatient admissions $200 copay 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 $2,600 per member $5,200 per family $5,000 per member $10,000 per family $7,000 per member $14,000 per family If any individual in the plan reaches the single out-of-pocket expenses before the family out-of-pocket maximum is met, the cost of that individual’s in-network, eligible care will be covered for the rest of the plan year. 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 – 90% after deductible Covered – 80% after deductible Covered – 60% of R&C after deductible Other 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%20Aetna%20Health%20Savings%20PPO%20South%20Bend%20Summary%203_1_2018.docx