Palo Verde Elementary School District
Medical Plans HDHP 1500 In Network
Classic Gold
Copay Gold
In Network
In Network
Aetna
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Aetna
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Aetna
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Lifetime Maximum Calendar Year
Unlimited Unlimited
Unlimited Unlimited
Unlimited Unlimited
Unlimited Unlimited
Unlimited Unlimited
Unlimited Unlimited
Deductibles Individual Family Coinsurance
$2,000 $4,000** 20%
$1,500 $3,000** 20%
$300 $900 15%
$240 $720 15%
None None N/A
None None N/A
Out-of-Pocket Maximum Individual Family
$5,500 $11,000
$4,500 $9,000
$4,000 $8,000
$3,200 $6,400
$6,350 $12,700
$5,080 $10,160
$250 + Deductible, then 20%
$200 + Deductible, then 20%
$250 Copay, then 15%
$200 Copay, then 15%
$250 Copay
$200 Copay
Deductible, then 20% Deductible, then 20% Deductible then $45 copay
Deductible, then 20% Deductible, then 20% Deductible then $40 copay
Deductible, then 15% Deductible, then 15% Deductible, then 15% Deductible, then 15% $45 $38
$75 Copay $150 Copay $50 Copay
$60 Copay $120 Copay $40 Copay
Routine Services Office Visit Specialist Visit Preventive Care Lab & X-Ray Chiropractic Rehabilitation
Deductible, then $25 Copay Deductible, then $35 Copay Covered in full Deductible, then 20% Deductible, then 20% Deductible, then 20%
Deductible, then $20 Copay Deductible, then $30 Copay Covered in full Deductible, then 20% Deductible, then 20% Deductible, then 20%
$25 Copay $35 Copay Covered in Full $25 Copay $25 Copay $25 Copay
$30 Copay $40 Copay Covered in Full $30 Copay $30 Copay $30 Copay
$24 Copay $32 Copay Covered in Full $24 Copay $24 Copay $24 Copay
Prescription Drugs Tier 1 Tier 2 Tier 3 Tier 4 Specialty Mail-Order Diabetic Medications
Deductible then: $15 Copay 20% Copay ($25 min/$80 max) 40% Copay ($40 min/$110 max) 20% Copay ($100 min/$150 max) 2x Retail $5 Generic, $15 Brand
Hospital Services Inpatient Hospital Outpatient Hospital Emergency Room Urgent Care
$20 Copay $28 Copay Covered in full $20 Copay $20 Copay $20 Copay
$15 Copay 20% Copay ($25 min/$80 max) 40% Copay ($40 min/$110 max) 20% Copay ($100 min/$150 max) 2x Retail $5 Generic, $15 Brand
$15 Copay 20% Copay ($25 min/$80 max) 40% Copay ($40 min/$110 max) 20% Copay ($100 min/$150 max) 2x Retail $5 Generic, $15 Brand
**If you have Family coverage under the HDHP 1500, the Family Deductible must be satisfied before the plan will pay any benefits.
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