Medical
DEX Imaging offers two medical plans through Meritain. The below chart provides an overview and comparison of these plans. To find a participating provider, visit www.aetna.com and select “find a doctor”. DEX Imaging uses the Aetna Choice POS II network.
Option A CORE
Option B BUY‐UP
IN‐NETWORK CALENDAR DEDUCTIBLE (the amount you are responsible for before Meritain shares in claims costs) Individual / Family $2,000 / $4,000 COINSURANCE (percent of claims costs you pay once you’ve met the deductible) 40% OUT OF POCKET MAXIMUM (the maximum you will pay for covered services in a calendar year) Individual / Family $6,350 / $12,700
$1,500 / $3,000
10%
$3,000 / $6,000
Maximum Includes
Deductible, Coinsurance, Copays & Prescriptions
PREVENTIVE CARE Wellness, Immunizations & Mammograms OFFICE VISITS PCP or Referral Required
Covered 100%
No
Office Visits (Illness / Injury)
$60 Copay
$60 Copay
Specialist Visits
40% after deductible
10% after deductible
HOSPITAL SERVICES Inpatient Hospital Outpatient Surgery Emergency Room
40% after deductible 40% after deductible 40% after deductible 40% after deductible
10% after deductible 10% after deductible 10% after deductible 10% after deductible
Urgent Care
DIAGNOSTIC TESTING Independent/Freestanding Lab
40% after deductible 40% after deductible
10% after deductible 10% after deductible
Complex Diagnostic
PRESCRIPTIONS
Generics: Covered 100% (Deductible waived) Brand copays apply after Deductible: Preferred: $50 Non‐Preferred: $75 Injectables: $125 Generics: Covered 100% (Deductible waived) Brand copays apply after Deductible: Preferred: $125 Non‐Preferred: $187.50
Generics: Covered 100% (Deductible waived) Brand copays apply after Deductible: Preferred: $30 Non‐Preferred: $50 Injectables: $125 Generics: Covered 100% (Deductible waived) Brand copays apply after Deductible: Preferred: $75 Non‐Preferred: $125
Retail (30 day supply)
Mail Order (90 day supply) Mandatory for all maintenance medications. Can be obtained at either a CVS retail store or through Caremark Mail‐order service.
The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
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