Employee Benefits At AGlance Medical - Aetna
In-Network Coinsurance (Member pays) Deductible Employee | Family Out of Pocket Maximum (Includes deductible) Employee | Family Office Visit Preventive TeleDoc (Telemedicine) PCP (Primary Care Provider) Specialist Emergency Treatment ER (waived if admitted) Urgent Care Inpatient Services Outpatient Services Prescription Copays (Non-Specialty) Out-of -Network Coinsurance (Member pays) Deductible Employee | Family Out of Pocket Maximum (Includes deductible) Employee | Family
Per Pay Period (24) Employee Only Employee + Spouse Employee + Child(ren) Family
$2,000 100/50% Plan
$3,000 100/50% Plan
$5,000 100/50% HSA Plan
0%
0%
0%
$2,000 | $4,000
$3,000 | $6,000
$5,000 | $10,000
$5,000 | $10,000
$6,000 | $12,000
$6,000 | $12,000
$0 copay $0 copay $25 copay $75 copay
$0 copay $0 copay $35 copay $75 copay
$0 copay $49 copay Deductible Deductible
$500 $75 copay Deductible Deductible
$300 copay + Ded $75 copay Deductible Deductible
$10/$45/$75/20% up to $250
$15/$45/$75/20% up to $250
$500 copay Deductible Deductible Deductible Deductible $15/$50/$100/20% up to $250
50%
50%
50%
$4,000 | $12,000
$6,000 | $18,000
$10,000 | $30,000
$14,000 | $42,000
$16,000 | $48,000
$20,000 | $60,000
$2,000 100/50% Plan
$3,000 100/50% Plan
$5,000 100/50% HSA Plan
$85.30 $417.74 $376.18 $680.93
$78.21 $380.69 $342.87 $620.16
$63.96 $295.56 $265.27 $487.34
This documents is intended as a summary of the major points of the benefits plans. Please refer to all plan summaries for limitations and exclusions.