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Not all coverage is the right coverage.

Your healthcare coverage is important to us. Age, family status, medical conditions, hobbies, lifestyle and a myriad of other factors will help you determine if you need a lot or a very little amount of health coverage. This summary will help you understand your plan and its coverage.

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Summary of Medical Benefits

$2,500 PPO Plan

Tier 1

Tier 2

Out of Network

Deductible

Individual

Family

 

$0

$0

 

$2,500

$5,000

 

$7,000

$14,000

Out-of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

$4,500

$9,000

 

$8,000

$16,000

Preventive Care Services

No Charge

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

No Charge

No Charge

No Charge

 

20%*

20%*

20%*

 

40%*

40%*

40%*

Urgent Care Services

No Charge

20%*

40%*

Complex Imaging: MRI/CT/PET Scans

No Charge

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

No Charge

No Charge

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

No Charge

No Charge

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

No Charge

No Charge

 

20%*

20%*

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$40 Copay

$90 Copay

$150 Copay

Mail Order 90 Day Supply

$20 Copay

$80 Copay

$180 Copay

Not Covered

 

 

 

 

 

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial

Evaluation

Mental Health - Psychiatrist, Ongoing

Session

No Charge

No Charge

No Charge

 

No Charge

 

No Charge

 

No Charge

No Charge

No Charge

 

No Charge

 

No Charge

 

No Charge

No Charge

No Charge

 

No Charge

 

No Charge

 

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

If you are outside the America's PPO service area, your tier 2 network is Aetna.

 

 

 

$3,400 HDHP Plan

Tier 1

Tier 2

Out of Network

Deductible

Individual

Family

 

$1,700

$3,400

 

$3,400

$6,800

 

$8,000

$16,000

Out-of-Pocket Maximum

Individual

Family

 

$3,400

$6,800

 

$6,600

$13,200

 

$9,000

$16,000

Preventive Care Services

No Charge

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

20%*

20%*

20%*

 

40%*

40%*

40%*

Urgent Care Services

20%*

20%*

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

20%*

20%*

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

20%*

20%*

20%*

20%*

Mail Order 90 Day Supply

20%*

20%*

20%*

Not Covered

 

 

 

 

 

Teladoc Benefits

General Consutlations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial

Evaluation

Mental Health - Psychiatrist, Ongoing

Session

No Charge

No Charge

No Charge

 

No Charge

 

No Charge

 

No Charge

No Charge

No Charge

 

No Charge

 

No Charge

 

No Charge

No Charge

No Charge

 

No Charge

 

No Charge

 

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

 

 

If you are outside the America's PPO service area, your tier 2 network is Aetna.

 

 

 

$2,500 Aetna PPO Plan

Tier 1

Out of Network

Deductible

Individual

Family

 

$2,500

$4,500

 

$7,000

$14,000

Out-of-Pocket Maximum

Individual

Family

 

$4,500

$9,000

 

$8,000

$16,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

40%*

40%*

40%*

Urgent Care Services

20%*

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

$60 Copay

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

$10 Copay

$40 Copay

$90 Copay

$150 Copay

Mail Order 90 Day Supply

$20 Copay

$80 Copay

$180 Copay

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

 

 

No Charge

No Charge

No Charge

No Charge

 

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

$3,400 Aetna PPO Plan

Tier 1

Out of Network

Deductible

Individual

Family

 

$3,400

$6,800

 

$8,000

$16,000

Out-of-Pocket Maximum

Individual

Family

 

$6,600

$13,200

 

$9,000

$16,000

Preventive Care Services

No Charge

40%*

Office Visits

Primary Office Visit

Specialist Office Visit

Chiropractic Visit

 

20%*

20%*

20%*

 

40%*

40%*

40%*

Urgent Care Services

20%*

40%*

Complex Imaging: MRI/CT/PET Scans

20%*

40%*

Inpatient Hospital Care

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Outpatient Procedures

Facility Fee

Physician Fee

 

20%*

20%*

 

40%*

40%*

Emergency Room

Emergency Medical Transportation

20%*

20%*

20%*

20%*

Mental Health/Chemical Dependency

Inpatient

Office Visit

 

20%*

20%*

 

40%*

40%*

Prescription Drug Coverage

Generic

Preferred Brand

Non-Preferred Brand

Specialty

Retail 30 Day Supply

20%*

20%*

20%*

20%*

Mail Order 90 Day Supply

20%*

20%*

20%*

Not Covered

Teladoc Benefits

General Consultations

Dermatology

Mental Health - Therapist

Mental Health - Psychiatrist, Initial Evaluation

Mental Health - Psychiatrist, Ongoing Session

 

No Charge

No Charge

No Charge

No Charge

 

 

No Charge

No Charge

No Charge

No Charge

 

NOTE: * Coinsurance After Deductible

Please refer to your Summary Plan Description for actual coverage, limitation, and exclusion provisions

 

 

 

 

If you prefer talking with a HealthEZ representative, call 844-204-3759