Malone Office Equipment
April 1, 2023 Medical Renewal
Aetna Copay Plan
Axis Gap Plan
Insurance Carrier: Plan Type: In-Network
$40
$40 $80 $100
Office Visit Copay - Primary Care Office Visit Copay - Specialist Care Urgent Care Copay
$80 $100
$0 $0 $0 $0
$500 Copay; waived if admitted $0 Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
Emergency Room Care Preventative Visit Copay Diagnostic Testing & Blood Work Advanced Imaging Coinsurance Employee Deductible Family Deductible Employee Out-of-Pocket Max Family Out-of-Pocket Max Inpatient Hospital Outpatient Hospital or Facility Prescription Drugs Rx Deductible Tier 1 (Generic) Tier 2 (Preferred) Tier 3 (Non-Preferred) Tier 4 (Specialty)
100% $7,350
100% $0 $0
$14,700 $8,150 (includes deductible)
$800 (includes deductible) $1,600 (includes deductible)
Deductible; then 100% Coinsurance $16,300 (includes deductible) Deductible; then 100% Coinsurance
$0 $0
$0
$0 $3 / $10
$3 / $10 $50 $80
$50 $80 80% up to $250 / 60% up to $500
Copays - 30 Day Supply
80% up to $250 / 60% up to $500
Employee Monthly Deduction Employee Only
$919.41 $838.95 $275.89
Employee + Spouse Employee + Child(ren)
Family
$1,428.86
Employee Semi-Monthly Deduction Employee Only
$212.17 $193.60 $63.67 $137.95 $459.71 $419.48 $714.43 $329.74
Employee + Spouse Employee + Child(ren)
Family
Employee Weekly Deduction Employee Only
Employee + Spouse Employee + Child(ren)
Family
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