Medical Plans

Palo Verde Elementary School District

Medical Plans

HDHP 1500 In Network

Classic Gold Copay Gold In Network In Network

Aetna Banner Aetna Banner Aetna Banner

Lifetime Maximum Unlimited Calendar Year 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

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

Hospital Services Inpatient Hospital $250 + Deductible, then 20% $200 + Deductible, then 20% $250 Copay, then 15% $200 Copay, then 15% $250 Copay

Outpatient Hospital Deductible, then 20% Deductible, then 20% Deductible, then 15% Deductible, then 15% $75 Copay Emergency Room Urgent Care Deductible, then 20% Deductible, then 20% Deductible, then 15% Deductible, then 15% $150 Copay Deductible then $45 copay Deductible then $40 copay $45 $38 $50 Copay None None N/A

$5,080 $10,160

$200 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 $20 Copay $25 Copay Deductible, then $35 Copay Deductible, then $30 Copay $35 Copay $20 Copay $28 Copay

Covered in full Covered in full

Covered in Full Covered in full Deductible, then 20% Deductible, then 20% $25 Copay Deductible, then 20% Deductible, then 20% $25 Copay Deductible, then 20% Deductible, then 20% $25 Copay $20 Copay $20 Copay $20 Copay

Prescription Drugs Deductible then: Tier 1 $15 Copay Tier 2 20% Copay ($25 min/$80 max)

Tier 3 40% Copay ($40 min/$110 max)

Tier 4 Specialty 20% Copay ($100 min/$150 max)

Mail-Order

2x Retail Diabetic Medications $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 $30 Copay $40 Copay

$24 Copay $32 Copay Covered in Full Covered in Full $30 Copay $30 Copay $30 Copay $24 Copay $24 Copay $24 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

**If you have Family coverage under the HDHP 1500, the Family Deductible must be satisfied before the plan will pay any benefits.