Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Medical Plan 1
Plan Information
Plan Name: Aetna HMO
Policy Number: 00000
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Primary Care Visit
$30 copay, then 0%
Specialist Visit
$30 copay, then 0%
Chiropractic Visit
Not covered
Lab and X-ray
Complex imaging: $50 copay, then 0%
All other: $10 copay, then 0%
Urgent Care
$30 copay
Emergency Room
$100 copay, then 0%
(copay waived if admitted)
Hospitalization
1st 5 days: $500 copay per day, then 0%
Thereafter: Covered 100%
Outpatient Surgery
$200 copay, then 0%
Retail RX (Up to 30-Day Supply)
Deductible
$100
Out-of-Pocket Maximum
Subject to medical out-of-pocket maximums
Generic Preferred
$5 copay, then 0%
Generic Non-Preferred
$10 copay, then 0%
Brand Preferred
$35 copay*
Brand Non-Preferred
Not covered
* After Rx deductible
Plan Documents
Contact Information
Medical Plan 2
Plan Information
Plan Name: Aetna PPO
Policy Number: 22222
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
Level 1
Deductible
(Individual/Family)
$1,000/$3,000
Out-of-Pocket Max
(Individual/Family)
$4,500/$9,000
Primary Care Visit
$20 copay, then 0%
Specialist Visit
$20 copay, then 0%
Chiropractic
20%* (up to 10 visits
per calendar year)
Lab and X-ray
First $400: Covered 100%
Thereafter: 20%*
Urgent Care
$35 copay, then 0%
Emergency Room
$100 copay, then 20%*
(copay waived if admitted)
Hospitalization
20%*
Outpatient Surgery
20%* (ambulatory surgical centers: 10%*)
Retail RX
(Up to 30-Day Supply)
Deductible
None
Out-of-Pocket Max
Subject to medical
out-of-pocket maximums
Generic Preferred
$10 copay, then 0%
Generic Non-Preferred
$10 copay, then 0%
Brand Preffered
$35 copay, then 0%
Brand Non-Preffered
$75 copay, then 0%
Level 2
Deductible
(Individual/Family)
$1,000/$3,000
Out-of-Pocket Max
(Individual/Family)
$4,500/$9,000
Primary Care Visit
$35 copay, then 0%
Specialist Visit
$35 copay, then 0%
Chiropractic
40%* (up to 10 visits
per calendar year)
Lab and X-ray
First $400: Covered 100%
Thereafter: 40%*
Urgent Care
$35 copay, then 0%
Emergency Room
$100 copay, then 20%*
(copay waived if admitted)
Hospitalization
40%*
Outpatient Surgery
40%*
–
Retail RX
(Up to 30-Day Supply)
Deductible
None
Out-of-Pocket Max
Combined with level 1
–
Generic Preferred
$10 copay, then 0%
Generic Non-Preferred
$10 copay, then 0%
Brand Preferred
$35 copay, then 0%
Brand Non-Preferred
$75 copay, then 0%
Level 3
Deductible
(Individual/Family)
$1,000/$3,000**
Out-of-Pocket Max
(Individual/Family)
$4,500/$9,000**
Primary Care Visit
40%*
Specialist Visit
40%*
Chiropractic
40%* (up to 10 visits
per calendar year)
Lab and X-ray
Not covered
–
Urgent Care
40%*
Emergency Room
$100 copay, then 20%*
(copay waived if admitted)
Hospitalization
40%*
Outpatient Surgery
40%*
–
Retail RX
(Up to 30-Day Supply)
Deductible
None
Out-of-Pocket Max
Combined with level 1
–
Generic Preferred
$10 copay, then 0%
Generic Non-Preferred
$10 copay, then 0%
Brand Preffered
$35 copay, then 0%
Brand Non-Preffered
$75 copay, then 0%
–
* After deductible
** Combined with level 1 and 2
Plan Documents
Contact Information
Medical Plan 3
Plan Information
Plan Name: Aetna HSA-Compatible PPO
Policy Number: 12345
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000 (offset by HSA funds)
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Primary Care Visit
10%*
Specialist Visit
10%*
Chiropractic
10%* (up to 30 visits per calendar year)
Lab and X-ray
10%*
Urgent Care
10%*
Emergency Room
10%*
Hospitalization
10%*
Outpatient Surgery
10%*
Retail RX
(Up to 30-Day Supply)
Deductible
Subject to medical deductible
Out-of-Pocket Max
Subject to medical out-of-pocket maximums
Generic Preferred
$5 copay, then 0%*
Generic Non-Preferred
$5 copay, then 0%*
Brand Preferred
$15 copay, then 0%*
Brand Non-Preferred
$25 copay, then 0%*
* After deductible
Out-of-Network
Deductible (Individual/Family)
$4,000/$8,000 (offset by HSA funds)
Out-of-Pocket Max (Individual/Family)
$5,000/$24,000
Primary Care Visit
50%*
Specialist Visit
50%*
Chiropractic
50%* (up to 30 visits per calendar year)
Lab and X-ray
50%*
Urgent Care
50%*
Emergency Room
50%*
Hospitalization
50%*
Outpatient Surgery
50%*
Retail RX
(Up to 30-Day Supply)
Deductible
Subject to medical deductible
Out-of-Pocket Max
Subject to medical out-of-pocket maximums
Generic Preferred
50%*
Generic Non-Preferred
50%*
Brand Preferred
50%*
Brand Non-Preferred
50%*
Plan Documents
Contact Information
Medical Plan 4
Plan Information
Plan Name: Aetna POS
Policy Number: 24687
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
HMO Level
Deductible
(Individual/Family)
None
Out-of-Pocket Max
(Individual/Family)
No limit
Primary Care Visit
$15 copay, then 0%
Specialist Visit
$15 copay, then 0%
Chiropractic
$10 copay, then 0%
Lab and X-ray
Covered 100%
Urgent Care
$50 copay, then 0%
–
Emergency Room
$50, then 0%
(copay waived if admitted)
Hospitalization
Covered 100%
Outpatient Surgery
$15 copay, then 0%
Retail RX
(Up to 30-Day Supply)
Deductible
None
Out-of-Pocket Max
Subject to medical
out-of-pocket maximums
Generic Preferred
$5 copay, then 0%
Generic Non-Preferred
$10 copay, then 0%
Brand Preffered
$20 copay, then 0%
Brand Non-Preffered
$20 copay, then 0%
* After deductible
POS In-Network
Deductible
(Individual/Family)
$200/$600
Out-of-Pocket Max
(Individual/Family)
$2,000/$4,000
Primary Care Visit
20%*
Specialist Visit
20%*
Chiropractic
Not covered
Lab and X-ray
20%*
Urgent Care
Covered (see contract
for limitations)
Emergency Room
$50 copay, then 0%*
(copay waived if admitted)
Hospitalization
20%*
Outpatient Surgery
20%*
Retail RX
(Up to 30-Day Supply)
Deductible
None
Out-of-Pocket Max
Subject to medical
out-of-pocket maximums
Generic Preferred
Not covered
Generic Non-Preferred
Not covered
Brand Preferred
Not covered
Brand Non-Preferred
Not covered
POS Out-of-Network
Deductible
(Individual/Family)
$500/$1,000
Out-of-Pocket Max
(Individual/Family)
$4,000/$8,000
Primary Care Visit
40%*
Specialist Visit
40%*
Chiropractic
Not covered
Lab and X-ray
Not covered
Urgent Care
Covered (see contract
for limitations)
Emergency Room
$50 copay, then 0%*
(copay waived if admitted)
Hospitalization
40%* (up to $600 per day)
Outpatient Surgery
40%* (up to $350 per day)
Retail RX
(Up to 30-Day Supply)
Deductible
None
Out-of-Pocket Max
Subject to medical
out-of-pocket maximums
Generic Preferred
Not covered
Generic Non-Preferred
Not covered
Brand Preffered
Not covered
Brand Non-Preffered
Not covered